Hemodilution therapy for lacunar stroke: Treatment results in 10 consecutive cases

Because precipitous neurological deterioration occurred during blood pressure reduction in a seminal case of lacunar infarction, nine subsequent patients with acute partial or evolving lacunar deficits were treated with hemodilution and blood pressure nonintervention to test the hypothesis that lacunar infarction represents perfusion failure. Isovolemic hemodilution was performed using hetastarch with target hematocrit of 30-33. Pretreatment brain computed tomography, carotid ultrasound, and echocardiography were normal. Nine patients recovered normal neurological function, and two regained complete functional independence in close temporal correlation with hemodilution and within 7 days of symptom onset. Magnetic resonance imaging of the brain demonstrated appropriate single white matter lesions in nine cases. No specific risk factor combination could be identified. No patient has had recurrent stroke in follow-up from 18 to 36 months. Response to hemodilution suggests the possibility of a hemodynamic pathophysiology. Successful treatment requires (a) blood pressure nonintervention and (b) hemodilution prior to severe clinical deterioration. A controlled trial seems indicated.