# The most common type of stroke may have had the wrong cause for decades > Introduction: a medical certainty starts to wobble - Author: Maxime Marquette - Publisher: MadMax (https://mad-max.co) - Section: Column - Published: 2026-07-04 - Canonical URL: https://mad-max.co/en/article/lavc-le-plus-frequent-aurait-la-mauvaise-cause-depuis-des-decennies ## Introduction: a medical certainty starts to wobble ### The story we've always been told For decades, **medicine** told a simple story about **stroke**: **arteries** clogging up, fat building up, a **clot** eventually cutting off blood flow to part of the **brain**. This story justified entire classes of **treatments**, from **statins** to **antiplatelet drugs**, prescribed to millions of **patients** worldwide. A new **study** published in the journal **Circulation** is now shaking that certainty for one of the most common types of **stroke**: **lacunar stroke**. According to **researchers** at the **University of Edinburgh**, the main cause may not be the narrowing of **large arteries**, but rather the deterioration of much smaller, deeper vessels, whose walls dilate and lose their ability to regulate blood flow. ### Why this **discovery** changes everything This is not an academic detail confined to specialized journals. If the actual cause of **lacunar stroke** differs from what was long assumed, then the standard treatments prescribed to thousands of patients every year could be largely ineffective for this specific form of stroke, a conclusion the authors themselves do not hesitate to state plainly. Lead researcher **Joanna Wardlaw**, professor of applied neuroimaging at the **University of Edinburgh**, sums up the significance of the **discovery** with a candor rarely seen in the scientific world: conventional treatments are not working as expected, and it's time to acknowledge that openly. *There's something both unsettling and reassuring about this kind of revelation: unsettling because we realize we may have mistreated people for years, reassuring because **science** has the courage to correct itself.* ## What exactly is a **lacunar stroke** ### A quiet but common form of stroke **Lacunar stroke** accounts for roughly a quarter of all **ischemic strokes**, which themselves make up about **87%** of all strokes. Unlike more dramatic strokes affecting **large arteries**, **lacunar stroke** occurs in the deep, subcortical regions of the **brain**, often with more subtle symptoms, which does not make it any less dangerous. This type of stroke is closely tied to what specialists call **cerebral small vessel disease**, a progressive deterioration of the deep **blood vessels** of the **brain** whose exact **mechanisms** remained unclear for a long time, despite its considerable **clinical** importance. ### Why **small vessels** were long neglected **Cardiovascular** **research** has historically focused on large **arteries**, easier to image and more directly linked to heart attacks and massive strokes. The deep **small vessels** of the brain, by comparison, are technically harder to observe and have therefore received disproportionately little scientific attention relative to their actual role in brain health. This methodological gap partly explains why it took a study this rigorous, combining **magnetic resonance imaging** with longitudinal follow-up, to finally isolate the specific role of these vessels in the onset of **lacunar stroke**. *It always strikes me how science sometimes advances not by discovering something new, but by finally daring to look at what had been neglected out of sheer technical convenience.* ## The **Edinburgh** study: methodology and scale ### A cohort followed over several years Researcher **Joanna Wardlaw's** **team** analyzed **data** from **229 patients** who had suffered a **stroke**, as part of a cohort called the **Mild Stroke Study 3**, recruited in **Edinburgh** between **2018 and 2021**. Among these patients, **131** had specifically suffered a **lacunar stroke**, while the others had experienced a mild non-lacunar form of stroke. Each participant underwent a series of **clinical** assessments and a **brain magnetic resonance imaging** scan at recruitment, then again one year later, allowing **researchers** to observe the actual evolution of blood vessels over time rather than a single static snapshot of brain condition. ### What the researchers precisely measured The scientists focused on two distinct phenomena: the narrowing of large **arteries**, long considered the main **risk** factor for **ischemic strokes**, and the widening and lengthening of **small arteries** located deep within the brain, a phenomenon far less studied until now. This comparative approach made it possible, for the first time with this level of precision, to isolate which of these two **mechanisms** was truly associated with **lacunar stroke** and **cerebral small vessel disease**, rather than simply assuming the two necessarily went hand in hand. *This kind of methodological rigor, following the same patients over several years rather than relying on a single snapshot, is exactly the kind of scientific patience too often missing from medical research in a hurry to publish quickly.* ## The result that upends everything: widened vessels, not narrowed ones ### An association **four times** stronger than expected The study's central finding is unambiguous: the narrowing of large arteries was associated with neither **lacunar stroke** nor any marker of **cerebral small vessel disease**. By contrast, patients whose scans showed widening and lengthening of the brain's **small arteries** were **four times** more likely to have suffered a **lacunar stroke**. This association proved strongly correlated with nearly every marker of **cerebral small vessel disease** measured by the **team**, a result **Joanna Wardlaw** calls solid **evidence** that **lacunar stroke** is not caused by fatty blockage of large arteries, but by a disease specific to the brain's small vessels themselves. ### The "baggy" vessel mechanism According to the researcher, the widening observed could signal a loss of the normal supporting membranes in the walls of large arteries, making the blood vessels literally more "loose," or "baggy" as she puts it, and therefore less able to properly regulate blood flow. The team believes the same phenomenon affects the much smaller arterioles inside the brain. This loss of vascular control, rather than simple physical blockage of a pipe by fatty deposits, would explain why damaged small brain vessels struggle to adjust their diameter to the needs of surrounding brain tissue, eventually causing the lesions characteristic of **lacunar stroke**. *The image of blood vessels turned "baggy," loose, unable to contract normally, is almost more troubling than a simple blockage: this is an entire structure losing its capacity for regulation, not just a clogged pipe.* ## Why current treatments fall short ### Drugs designed for a different mechanism The standard treatments prescribed after an **ischemic stroke**, such as **antiplatelet drugs** or **aspirin**, were designed to prevent clot formation in arteries narrowed by fat buildup. But if **lacunar stroke** actually results from structural degradation of small vessels, these drugs are simply targeting the wrong mechanism. This is precisely what **Joanna Wardlaw** points to when she explains that recognizing this distinction is crucial, since it explains why conventional treatments like **antiplatelet drugs** are not as effective for this type of stroke, while stressing the urgency of developing new therapies that directly target the underlying microvascular damage. ### Limited efficacy acknowledged by the authors themselves In their conclusions, the study's authors go so far as to write that standard secondary **prevention** for stroke, including antiplatelet therapy and **statins**, has limited efficacy in preventing the progression of brain damage related to small vessel disease, while specifying that these approaches remain important and should not be abandoned altogether. This nuance matters: it's not a claim that current treatments are useless, but that they clearly aren't enough on their own for this specific form of stroke, which justifies the urgent search for new, complementary therapeutic avenues. *This kind of scientific admission, openly saying that the standard treatment prescribed for years doesn't work as hoped for a subset of patients, takes an institutional courage we don't praise often enough.* ## The **LACI-3** **clinical trial**: a response underway ### Two existing drugs repurposed Faced with this finding, the **Edinburgh** team is currently running the **LACI-3** clinical trial, testing two drugs already used in cardiology and peripheral vascular **medicine**: **cilostazol** and **isosorbide mononitrate**. According to **Wardlaw**, these molecules could improve the function of the brain's small blood vessels and thereby better regulate cerebral blood flow. The trial's ultimate goal is to help prevent more **lacunar strokes**, as well as **cognitive decline** and other harmful effects associated with **cerebral small vessel disease**, a **public health** issue that extends well beyond the acute stroke episode alone. ### A nationwide study in the **United Kingdom** The **LACI-3** trial is currently running across **38 different centers** throughout the **United Kingdom**, with a recruitment target of **1,300 people** who have suffered a **lacunar stroke**. Participants will follow treatment for **18 months**, with **cognitive decline** as the main outcome measure. The trial is currently in its first year of recruitment, meaning definitive **results** likely won't be available for several years, a frustrating but necessary delay to ensure the scientific reliability of future conclusions. *Eighteen months of treatment, thirty-eight centers, thirteen hundred patients: these are numbers that remind us serious medicine advances at a pace that never matches our legitimate desire for immediate solutions.* ## **Silent strokes**, an underestimated danger ### Brain damage without apparent symptoms The study also revealed that just over a quarter of patients had suffered what researchers call a **silent stroke**, a small area of brain tissue damage caused by restricted **blood flow**, but which generally produces no perceptible symptoms. This occurred even in patients receiving standard preventive treatments. The term "silent" does not mean harmless: these lesions accumulate over time and significantly contribute to long-term **cognitive** decline, a link increasingly documented by vascular **neurology** research in recent years. ### Increased **risk** in the year following a first stroke Patients whose brain vessels showed marked widening also faced a higher risk of suffering a new **silent stroke** during the year following their initial assessment. This observation reinforces the idea that the underlying vascular deterioration is an ongoing process, not an isolated event resolved once initial treatment is administered. This continuity of risk justifies, according to the authors, closer monitoring of patients who have suffered a first **lacunar stroke**, rather than a one-off approach limited to the acute phase following the initial incident. *The idea of a stroke you don't even feel happening, yet which leaves a very real mark on the brain, should be enough to convince anyone to take long-term **medical follow-up** seriously, even without apparent symptoms.* ## The study's limitations, a necessary honesty ### One city, a limited patient pool The authors themselves acknowledge an important limitation: all the data come from stroke care services in a single city, **Edinburgh**. For these results to be generalizable to a broader population, larger studies including patients from several different geographic regions will be needed. This methodological caution takes nothing away from the solidity of the work done, but it's a reminder that a single study, however rigorous, is never enough on its own to definitively rewrite a medical textbook used for decades worldwide. ### A still-hypothetical genetic link The researchers also raise the possibility of a shared genetic link between artery widening, **lacunar stroke**, and **cerebral small vessel disease**, though they cannot definitively confirm this **hypothesis** with the data currently available. This lead will require further, more in-depth genetic research. Other explanations, such as additional mechanical stress placed on small vessels by the widening of neighboring arteries, also remain under study, showing that the full mechanism remains only partly understood despite this major advance. *I particularly appreciate it when researchers openly admit the limits of their own work: that's a sign of rigor, not weakness, and it deserves recognition in a world where everyone wants to announce a definitive revolution.* ## What this means for patients today ### Don't stop current treatments It's essential to clarify that this discovery does not mean patients should abandon their current treatments, such as **statins** or **antiplatelet** drugs prescribed by their doctor. These treatments remain relevant for the general prevention of **cardiovascular** disease, even though their specific efficacy against **lacunar stroke** is now being questioned. Any decision about changing treatment must be made in consultation with a medical team, not based on a piece of science journalism, however rigorous its presentation of the facts. ### Real hope, but not immediate For patients who have already suffered a **lacunar stroke**, this research represents real but not immediate hope: results from the **LACI-3** trial won't be known for several years, and no new approved treatment based specifically on this finding is available yet. This delay, while frustrating for those directly affected, matches the normal and necessary pace of rigorous clinical validation, without which no drug should ever be widely prescribed to the population. *I understand the frustration of wanting an immediate solution to such a serious disease, but rushing the adoption of a poorly validated treatment would likely cause more harm than good in the long run.* ## The real toll of stroke on our societies ### A leading cause of **disability** worldwide **Stroke** remains one of the leading causes of disability and death worldwide, a burden that affects health systems as much as families confronting the long-term consequences of a stroke, whether major or seemingly minor like **lacunar stroke**. The fact that **lacunar stroke** accounts for roughly a quarter of all **ischemic strokes** means any improvement in understanding and treating it could have concrete repercussions for the health of millions of people worldwide, well beyond the narrow circle of patients directly studied in **Edinburgh**. ### A societal issue, not just a laboratory one Beyond the statistics, each **lacunar stroke** represents a potentially upended life trajectory: loss of **independence**, progressive cognitive decline, an increased burden on **family caregivers**. Correctly understanding the true cause of this phenomenon is therefore not merely an academic question, but a societal issue with profound human implications. It is this human dimension that gives full weight to a discovery that could, eventually, transform how one of the most common types of stroke in the Western world is prevented and treated. *Behind every statistic about **lacunar stroke** is a person who may have lost the ability to drive, to work, or to live fully independently: it's this human reality that makes this research urgent, not merely interesting.* ## Other parallel avenues of research ### A mobilized global **scientific community** The **Edinburgh** team is not alone in studying **cerebral small vessel disease**. Several research groups around the world are currently exploring complementary approaches, ranging from advanced brain imaging to identifying blood **biomarkers** capable of detecting this vascular deterioration early, even before a first stroke occurs. This international scientific mobilization reflects a growing recognition that the brain's small vessels, long neglected in favor of large arteries, deserve research attention proportional to their real role in long-term brain health. ### Toward more targeted preventive medicine Eventually, this new understanding could pave the way for **screening** tools capable of identifying patients at high risk of **lacunar stroke** before a first event even occurs, enabling far more targeted prevention than the current general approach based on classic cardiovascular risk factors. This prospect, while still distant, illustrates how a single well-conducted study can redefine an entire research trajectory for years to come, with potential ripple effects well beyond the initial circle of researchers involved. *It's fascinating to see how a study of **229 patients** in a single Scottish city could potentially reshape an entire medical discipline worldwide: science sometimes works exactly like that, in small, decisive leaps.* ## What family doctors need to know now ### Adjusting the message without spreading panic For frontline doctors, this research poses a delicate communication challenge: how to incorporate this new knowledge without unnecessarily alarming patients already on treatment, or suggesting a premature abandonment of therapies that retain general preventive value for cardiovascular health. The best approach, according to several experts consulted in coverage of this study, is to present this discovery as a promising avenue still in development, rather than as a complete and immediate overturning of currently established care protocols. ### A call for greater clinical vigilance This study could nonetheless encourage clinicians to pay closer attention to signs of possible **cerebral small vessel disease** in their patients, notably through a more careful reading of **brain MRI** images already taken as part of standard post-stroke follow-up. This heightened vigilance, without immediately upending established practices, could contribute to earlier detection of at-risk patients, while awaiting the final results of the **LACI-3** trial and other similar research currently underway around the world. *This kind of scientific transition, gradually adjusting clinical practice while awaiting definitive proof, demands a difficult balance between caution and openness to change, an exercise family doctors perform daily without always getting credit for it.* ## What this story teaches us about medicine itself ### Science as a process, never as a fixed truth This discovery illustrates a fundamental reality too often forgotten in public debate about medicine: science is never a definitively established truth, but an ongoing process of questioning, verification, and, sometimes, course correction in the face of new evidence stronger than what came before. Accepting that treatments prescribed for decades may prove less effective than expected for certain patients is not an admission of medicine's failure, but rather proof of its capacity to self-correct in the face of rigorous, methodologically sound data. ### Why scientific patience deserves our trust In a world saturated with sensationalist announcements of "miracle **breakthroughs**," this study stands out precisely for its modesty: its authors do not claim to have solved the problem of **lacunar stroke**, but to have identified a lead solid enough to justify a large-scale clinical trial spanning several years. This measured approach, far from being disappointing, should instead reassure the public: it is precisely this kind of rigor, without shortcuts or exaggerated promises, that has historically produced the most durable and reliable medical advances. *In a media landscape running on spectacular announcements, this study reminds us that real science often advances in small, cautious steps, and that it's precisely this apparent slowness that guarantees its long-term reliability.* ## The role of medical imaging in this breakthrough ### Scanners more precise than ever before This discovery would likely not have been possible without recent advances in **magnetic resonance imaging**, which now allow unprecedented precision in measuring the diameter and length of small brain arteries, structures once too fine to be analyzed reliably and reproducibly from one patient to another. This technical advance shows how scientific breakthroughs often depend as much on the tools available as on the ideas themselves: without the ability to properly visualize these vessels, the hypothesis of their central role in lacunar stroke would have remained impossible to rigorously verify. ### A standard that could become widespread If the findings of **Joanna Wardlaw** and her team are confirmed in larger studies, this kind of detailed imaging of small brain arteries could eventually become standard in the clinical assessment of patients at risk of lacunar stroke, much as imaging of large arteries already is today for more classic strokes. This potential wider adoption will, however, depend on the availability of specialized equipment and the training of medical staff, two logistical challenges that could slow clinical adoption even if the scientific validity of the approach is confirmed by future research. *We often forget that behind every medical discovery lies a story about **technology** too: without better imaging tools, this team simply would not have been able to see what it ultimately proved.* ## Conclusion: a necessary revision, not an instant revolution ### What changes right now, and what awaits confirmation This study does not immediately change everyday clinical practice, but it plants an important milestone in understanding **lacunar stroke**. It invites researchers, doctors, and the general public to reconsider an assumption taken for granted for decades, without abandoning the therapeutic tools currently available. ### The next chapter will be written in the years ahead The results of the **LACI-3** trial, expected in several years, will determine whether the leads pursued by **Joanna Wardlaw's** team truly translate into new, effective treatments against **lacunar stroke**. In the meantime, this discovery serves as an essential reminder: even the best-established medical certainties deserve to be regularly tested against the facts. *If this column should leave you with just one impression, let it be this: medicine advances by doubting itself, and that's exactly why, despite everything, we can trust it.* **By Maxime Marquette, columnist** ## Columnist's transparency note ### Editorial stance I am not a journalist but a **columnist and analyst**. My expertise lies in observing and analysing the geopolitical, economic and strategic dynamics that shape our world. My work is to take political strategies apart, to understand global economic movements, to put the decisions of international actors in context and to offer analytical perspectives on the changes that are redefining our societies. I do not claim the cold objectivity of traditional journalism, which stops at reporting facts. **I claim analytical clarity**, rigorous interpretation and a deep understanding of the complex issues that concern us all. My role is to give meaning to the facts, to place them in their historical and strategic context, and to offer a critical reading of events. ### Method and sources This text keeps the basic distinction between **verified facts and interpretive analysis**. The rule never changes: a factual claim is published only when a verifiable source supports it, and the sources this article actually used are listed under **Sources**, never here. **Primary source families** used by the publication, when the story has them: official statements from governments and international institutions, public statements by political leaders, reports from intergovernmental organisations, dispatches from recognised international news agencies. **Secondary source families**: specialised publications, internationally recognised news media, analyses from established research institutions, reports from industry organisations. When an article cites statistical, economic or geopolitical data, it comes from the institutions that produce it (intergovernmental organisations, central banks, national statistics offices), and the exact institution is named under **Sources**. ### Nature of the analysis The analyses, interpretations and perspectives in the analytical sections of this article are a **critical, contextual synthesis** based on the information available, the trends observed and the expert comments cited in the sources consulted. My role is to interpret these facts, to set them in the context of today's geopolitical and economic dynamics, and to give them a coherent meaning within the larger story of the changes shaping our time. These analyses reflect expertise built through continuous observation of international affairs and an understanding of the strategic mechanisms that drive global actors. This article describes a documented state of affairs on its publication date, not a prediction: later developments may shift its outlook. No update is promised in advance; when an article is corrected or completed, the change is dated in the text. ## Sources ### Primary sources - ScienceDaily — Study on the true cause of lacunar stroke — July 3, 2026 - [National Institute on Aging — Research news](https://www.nia.nih.gov/news) - [American Heart Association — 2026 guideline for the early management of acute ischemic stroke](https://professional.heart.org/en/science-news/2026-guideline-for-the-early-management-of-patients-with-acute-ischemic-stroke) ### Secondary sources - [Medical News Today — Lacunar stroke linked to widening brain arteries — May 9, 2026](https://www.medicalnewstoday.com/articles/lacunar-stroke-linked-to-widening-brain-arteries) - [CIDRAP — Center for Infectious Disease Research and Policy](https://www.cidrap.umn.edu/) - [ScienceDaily — Health and medicine news](https://www.sciencedaily.com/news/health_medicine/) --- Source: Maxime Marquette, MadMax. 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