Baggy Arteries and Stroke Risk
BAGGY arteries, rather than large artery blockages, may drive lacunar stroke and cerebral small vessel disease progression, according to findings from a prospective mild stroke cohort.
The study challenges the long-standing assumption that fatty narrowing of larger arteries is a major contributor to lacunar ischemic stroke. Instead, widening and elongation of arteries in the brain, described clinically as dolichoectasia, showed a strong association with lacunar stroke, cerebral small vessel disease burden, and new infarcts over 1 year.
Blocked Arteries Were Not Linked to Small Vessel Disease
Researchers prospectively assessed 229 patients with lacunar or mild nonlacunar stroke. Participants underwent demographic, stroke related, cognitive, functional, and MRI assessments at baseline and again at 1 year. Large artery stenosis was defined as at least 50% intracranial or cervical artery stenosis, while basilar artery dolichoectasia was assessed using basilar artery diameter, bifurcation height, and lateral displacement.
Large artery stenosis was present in 20.5% of participants, while basilar artery dolichoectasia was present in 15.7%. After adjustment for age, sex, and vascular risk factors, large artery stenosis was associated with lower odds of lacunar versus nonlacunar stroke and showed no association with cerebral small vessel disease markers or incident infarcts.
Small Vessel Disease Findings Point to New Stroke Mechanisms
In contrast, basilar artery dolichoectasia was strongly associated with lacunar stroke, with an odds ratio of 4.67. It was also linked to higher cerebral small vessel disease scores, incident infarcts, and greater progression of white matter hyperintensities over 1 year. Similar patterns were seen with wider intracranial arteries.
These findings suggest that lacunar stroke may be driven less by atherosclerotic narrowing of large vessels and more by intrinsic microvascular pathology. The authors highlighted segmental arteriolar disorganization as a likely principal mechanism, supporting the need for diagnostic and therapeutic approaches that target the brain’s small vessels directly.
The findings may also help explain why aspirin and other antiplatelet drugs have limited effectiveness in preventing lacunar ischemic stroke. Emerging treatment strategies, including trials of cilostazol and isosorbide mononitrate, are now focusing on therapies designed to protect small vessel function and reduce recurrent stroke, cognitive decline, mobility problems, and dementia after lacunar stroke.
References
Han F et al. Implications of cranial arterial stenosis and dolichoectasia for cerebral small-vessel disease etiopathogenesis: findings from a prospective mild stroke cohort. Circulation. 2026;doi:10.1161/CIRCULATIONAHA.126.079493.
University of Edinburgh. Artery widening, not blockages, linked to common stroke. 2026. Available at: https://www.eurekalert.org/news-releases/1126808. Last accessed: 11 May 2026.
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