Can we stop the stuttering in stroke? Interventions in 40 patients with acute lacunes

Published:April 12, 2019DOI:


      • Stuttering lacunar syndromes are infrequent.
      • Their complex clinical features and pathophysiology defy a uniform treatment.
      • Intravenous alteplase is the choice of treatment within 4.5-h window.
      • A loading dose of aspirin-clopidogrel may be an option when alteplase is not.
      • Blood pressure augmentation may benefit some patients with labile blood pressure.



      Whether any treatment can stop fluctuations of stuttering lacunar syndromes (SLS) is unclear. Case reports have variably suggested effectiveness of intravenous thrombolysis, dual antiplatelet treatment, blood pressure augmentation and anticoagulation. We aim to describe our experience with different treatments used in in patients presenting with SLS and their effect on clinical fluctuations and functional outcome.


      We collected demographic and clinical data of consecutive adult patients with SLS. Descriptive summaries were reported as median and inter-quartile range (IQR) for continuous variables and as frequencies and percentages for categorical variables.


      Forty patients (72 ± 10 years, 36% female) were included. Pure motor syndrome (57%) was the most frequent clinical presentation. Clinical fluctuations stopped and the improvement was temporally related to aspirin-clopidogrel in 11/17 cases, intravenous thrombolysis in 4/6 cases, blood pressure augmentation in 1/3 cases and aspirin in 1/7 cases. Two patients continued fluctuating after IVT and later responded to blood pressure augmentation (n = 1) or aspirin-clopidogrel (n = 1).


      Aspirin plus clopidogrel may be followed by clinical improvement when intravenous thrombolysis is not an option. Blood pressure augmentation may beneficial as ad-on treatment in patients with labile blood pressure.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal


      Subscribe to Journal of the Neurological Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Fisher C.M.
        Lacunar strokes and infarcts: a review.
        Neurology. 1982; 32: 871-876
        • Chamorro A.
        • Sacco R.L.
        • Mohr J.P.
        • Foulkes M.A.
        • Kase C.S.
        • Tatemichi T.K.
        • et al.
        Clinical-computed tomographic correlations of lacunar infarction in the stroke data Bank.
        Stroke. 1991; 22: 175-181
        • Sacco S.
        • Marini C.
        • Totaro R.
        • Russo T.
        • Cerone D.
        • Carolei A.
        A population-based study of the incidence and prognosis of lacunar stroke.
        Neurology. 2006; 66: 1335-1338
        • Caplan L.R.
        Intracranial branch atheromatous disease: a neglected, understudied, and underused concept.
        Neurology. 1989; 39: 1246-1250
        • Wardlaw J.M.
        • Smith C.
        • Dichgans M.
        Mechanisms of sporadic cerebral small vessel disease: insights from neuroimaging.
        The Lancet Neurology. 2013; 12: 483-497
        • Donnan G.A.
        • O'Malley H.M.
        • Quang L.
        • Hurley S.
        • Bladin P.F.
        The capsular warning syndrome: pathogenesis and clinical features.
        Neurology. 1993; 43: 957-962
        • Paul N.L.
        • Simoni M.
        • Chandratheva A.
        • Rothwell P.M.
        Population-based study of capsular warning syndrome and prognosis after early recurrent TIA.
        Neurology. 2012; 79: 1356-1362
        • Vivanco-Hidalgo R.M.
        • Rodriguez-Campello A.
        • Ois A.
        • Cucurella G.
        • Pont-Sunyer C.
        • Gomis M.
        • et al.
        Thrombolysis in capsular warning syndrome.
        Cerebrovascular diseases (Basel, Switzerland). 2008; 25: 508-510
        • Tassi R.
        • Cerase A.
        • Acampa M.
        • D'Andrea P.
        • Guideri F.
        • Lo Giudice G.
        • et al.
        Stroke warning syndrome: 18 new cases.
        J. Neurol. Sci. 2013; 331: 168-171
        • Gonzalez Hernandez A.
        • Fabre Pi O.
        • Lopez Fernandez J.C.
        • Diaz Nicolas S.
        Thrombolysis in capsular warning syndrome.
        Medicina clinica. 2010; 134: 612-613
        • Asil T.
        • Ir N.
        • Karaduman F.
        • Cagli B.
        • Tuncel S.
        Combined antithrombotic treatment with aspirin and clopidogrel for patients with capsular warning syndrome: a case report.
        Neurologist. 2012; 18: 68-69
        • Fahey C.D.
        • Alberts M.J.
        • Bernstein R.A.
        Oral clopidogrel load in aspirin-resistant capsular warning syndrome.
        Neurocrit. Care. 2005; 2: 183-184
        • Kawano H.
        • Nakajima M.
        • Inatomi Y.
        • Yonehara T.
        • Ando Y.
        Loading dose of clopidogrel in combination with other antithrombotic therapy for capsular warning syndrome.
        J. Stroke Cerebrovasc. Dis. 2014; 23: 1265-1266
        • Lalive P.H.
        • Mayor I.
        • Sztajzel R.
        The role of blood pressure in lacunar strokes preceded by TIAs.
        Cerebrovasc. Dis. 2003; 16: 88-90
        • Ladeira F.
        • Barbosa R.
        • Calado S.
        • Viana-Baptista M.
        Capsular warning syndrome: the role of blood pressure.
        J. Neurol. Sci. 2017; 381: 20-21
        • Dobkin B.H.
        Heparin for lacunar stroke in progression.
        Stroke. 1983; 14: 421-423
        • Ozdemir O.
        • Beletsky V.
        • Chan R.
        • Hachinski V.
        Thrombolysis in patients with marked clinical fluctuations in neurologic status due to cerebral ischemia.
        Arch. Neurol. 2008; 65: 1041-1043
        • Marsh E.B.
        • Llinas R.H.
        Stuttering Lacunes: An Acute Role for Clopidogrel.
        Journal of neurology & translational neuroscience. 2014; 2
        • Camps-Renom P.
        • Delgado-Mederos R.
        • Martinez-Domeno A.
        • Prats-Sanchez L.
        • Cortes-Vicente E.
        • Simon-Talero M.
        • et al.
        Clinical characteristics and outcome of the capsular warning syndrome: a multicenter study.
        Int. J. Stroke. 2015; 10: 571-575
        • Group TNt-PSS
        Generalized efficacy of t-PA for acute stroke. Subgroup analysis of the NINDS t-PA stroke trial.
        Stroke. 1997; 28: 2119-2125
        • Bowry A.D.
        • Brookhart M.A.
        • Choudhry N.K.
        Meta-analysis of the efficacy and safety of clopidogrel plus aspirin as compared to antiplatelet monotherapy for the prevention of vascular events.
        Am. J. Cardiol. 2008; 101: 960-966
        • Johnston S.C.
        • Easton J.D.
        • Farrant M.
        • Barsan W.
        • Conwit R.A.
        • Elm J.J.
        • et al.
        Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA.
        N. Engl. J. Med. 2018; 379: 215-225
        • Powers W.J.
        • Rabinstein A.A.
        • Ackerson T.
        • Adeoye O.M.
        • Bambakidis N.C.
        • Becker K.
        • et al.
        Guidelines for the early Management of Patients with Acute Ischemic Stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2018; 49 (e46-e110)
        • Jeong H.G.
        • Kim B.J.
        • Yang M.H.
        • Han M.K.
        • Bae H.J.
        • Lee S.H.
        Stroke outcomes with use of antithrombotics within 24 hours after recanalization treatment.
        Neurology. 2016; 87: 996-1002
        • Fuseya Y.
        • Kawamura M.
        • Matsuda E.
        • Takada K.
        • Watanabe K.
        • Fujitake J.
        rt-PA with antithrombotic therapies in a case with capsular warning syndrome.
        Internal medicine (Tokyo, Japan). 2017; 56: 441-444