Middle Cerebral Artery Stroke and Lacunar vs Cortical Stroke Differences

Clinical Presentation

The American Heart Association notes that middle cerebral artery (MCA) strokes present with contralateral hemiparesis, sensory loss, homonymous hemianopsia, and either aphasia or neglect, depending on the hemisphere affected 1
The American College of Cardiology recommends recognizing that MCA strokes can cause sudden or rapid onset of focal neurological symptoms, including motor, sensory, language, and visual disturbances 1
Decreased level of consciousness or coma can occur, especially with basilar occlusion, as stated by the American Academy of Neurology 2, 3
Nausea and vomiting are common in basilar artery/posterior circulation strokes, according to the American Heart Association 2, 3
Brain stem compression can occur with cerebellar strokes causing edema, as noted by the American Academy of Neurology 2, 3

The American Heart Association states that lacunar strokes are small, subcortical infarctions caused by occlusive arteriopathy of deep penetrating vessels, typically presenting with classic lacunar syndromes without cortical signs 4
Lacunar strokes often present with pure motor hemiparesis, pure sensory stroke, ataxic hemiparesis, or dysarthria-clumsy hand syndrome, as described by the American College of Cardiology 4
The location of lacunar strokes is typically in deep brain structures, such as the basal ganglia, internal capsule, thalamus, or pons, according to the American Academy of Neurology 4
Lacunar strokes are usually small, with a size of ≤1.5 cm on neuroimaging, as stated by the American Heart Association 4

The American College of Cardiology notes that cortical strokes are larger infarctions involving the cerebral cortex, typically presenting with cortical signs and caused by large-vessel atherosclerosis or cardioembolism 4, 1
Cortical strokes often present with cortical signs, such as aphasia, neglect, hemianopsia, or cortical sensory loss, as described by the American Academy of Neurology 4, 1
The location of cortical strokes is typically in cortical or large subcortical areas, according to the American Heart Association 4
Cortical strokes are generally larger than lacunar strokes, with a size of >1.5 cm, as stated by the American College of Cardiology 4

The American Academy of Neurology recommends that both lacunar and cortical stroke patients undergo brain CT/MRI, ECG, glucose, electrolytes, renal function, CBC, PT/INR, and aPTT as part of their diagnostic workup 2, 5, 6
Lacunar stroke diagnosis requires exclusion of large-artery stenosis and cardioembolic sources, as noted by the American Heart Association 4
Cortical stroke diagnosis requires evaluation for carotid stenosis, cardiac sources, and aortic arch disease, according to the American College of Cardiology 4
Thrombolytic therapy eligibility is similar for both subtypes when within the time window, as stated by the American Academy of Neurology 7
The American Heart Association emphasizes the importance of aggressive blood pressure and diabetes control in lacunar stroke patients, targeting small vessel disease 4
The American College of Cardiology recommends antiplatelet therapy, statin therapy, carotid intervention if indicated, and anticoagulation for cardioembolic sources in cortical stroke patients 4

The American Heart Association recommends that a leg > arm weakness pattern is indicative of an ACA territory stroke 8
The American Heart Association suggests that face, arm, and leg weakness of equal distribution is characteristic of a lacunar stroke in the internal capsule or corona radiata 9
The American Heart Association notes that dysarthria alone, or slurred speech with intact comprehension, can be a sign of a lacunar or brainstem stroke 9
The American Heart Association states that macular sparing is a characteristic feature of PCA/occipital cortex strokes with collateral blood supply 8
The American Heart Association recommends considering small-vessel disease (lacunar stroke) in patients with hypertension and diabetes, characterized by small subcortical infarcts and no cortical signs 9

The American Heart Association recommends immediate CT or MRI to differentiate ischemic from hemorrhagic stroke, as clinical presentation alone is not reliable 10
The American Heart Association suggests using the NIHSS to quantify severity and guide treatment 11
The American Heart Association recommends checking blood pressure, but not treating aggressively unless >220/120 mmHg 11
The American Heart Association notes that immediate glucose testing is necessary to rule out hypoglycemia 11

The American Heart Association states that large-artery atherosclerosis is characterized by cortical infarcts, often preceded by TIA in the same territory, and carotid stenosis or intracranial stenosis on imaging 8
The American Heart Association suggests that cardioembolic strokes are characterized by large cortical infarcts, sudden onset with maximal deficit at onset, and atrial fibrillation, valvular disease, or recent MI 8
The American Heart Association notes that small-vessel disease (lacunar stroke) is characterized by small subcortical infarcts, classic lacunar syndromes, hypertension and diabetes as risk factors, and no cortical signs 9

The American Heart Association recommends assessing for thrombolysis eligibility if within 4.5 hours 11
The American Heart Association suggests considering the time window for treatment, establishing when the patient was last known well, and using creative questioning with time anchors to help determine the time of onset 11