The role of blood pressure in lacunar strokes preceded by TIAs.

Lacunar strokes (LS) are often preceded by repetitive transitory ischaemic attacks (TIAs) known as 'capsular warning syndrome'. The treatment of these symptoms remains controversial. Anticoagulants are often used in this situation, most of the time, however, with no or little benefit. Since it is not rare that these TIAs lead to a definite stroke, the therapeutic approach in the acute phase is very important. We report six patients presenting LS preceded by TIAs. All patients showed intermittent decrease of blood pressure (BP) coinciding with clinical worsening and leading to definite stroke in four of them. All were treated with full-dose intravenous heparin, which did not prevent further clinical deterioration. One patient received noradrenalin, which allowed stabilisation of the blood pressure values and complete resolution of the neurological symptoms. This observation suggests that in lacunar strokes preceded by TIAs monitoring and, if necessary, pharmacological increase of BP may prevent some patients from developing a definite stroke. Thus the 'capsular warning syndrome' could reflect a haemodynamic failure rather than repeated thrombo-embolism within the lumen of a single perforating arteriole.