It is encouraging to see that others are equally frustrated and concerned (if slightly more blunt) about the messy terminology that dogs the study of lacunar stroke, cerebral small vessel disease, leukoaraiosis, et cetera, et cetera—white matter changes to be absolutely impartial (‘Déja Vu Dogged Doggerel’).1
Two factors are required to advance the study of small vessel disease (not even that is a very good name): (1) standardize the terminology and (2) stop assuming causative mechanisms. A noncavitated white matter lesion (in other words leukoaraiosis) may simply be a lacune (hole) that never cavitated, ie, it arises from the same insult, via the same mechanism but reflects a different severity of insult to the lacune (hole) that does cavitate,2 or perhaps ‘holes’ are the result of a different mechanism. Alternatively, the lesion that cavitates may reflect not a different insult, or severity of insult, but a different patient response—ie, some people cavitate, some don’t. As Johnson so famously said, ‘it is common among men to mistake subsequences for consequences’. So, let’s call a spade a spade (or a hole a hole): do well-conducted well-designed studies to work out causes of leukoaraiosis and lacunes, which will likely turn out, as described by Landau, to be multiple and disparate.
The LADIS study was a huge trans-European effort that has provided new information about small vessel disease. The issues around terminology apply to most other large studies of this topic—LADIS was no exception. So my editorial3 was not ‘a devastating critique of LADIS’ specifically, but of the problem that has dogged this field for many years.4
So, don’t shoot the messenger! Let’s deal with the root cause by making positive suggestions that will encourage standardization of terminology, avoid assumptions regarding causation and then maybe we will see the origin of the black lacunar hole.
Sources of Funding
Dr. Wardlaw is partly funded by the SINAPSE Collaboration (www.sinapse.ac.uk).
Landau. “What is a lacune?: Déjà vu dogged doggerel! Stroke. 2009; 40: e498–e499.
Potter GM, Doubal F, Jackson CA, Sudlow C, Dennis MS, Wardlaw JM. Long-term appearance of lacunar infarction on imaging: what proportion become CSF-containing cavities? Cerebrovasc Dis. 2008; 25: 30.
Wardlaw JM. What is a lacune? Stroke. 2008; 39: 2921–2922.
Landau WM. Clinical Neuromythology VI. Au clair de lacune: holy, wholly, holey logic. Neurology. 1989; 39: 725–730.