Carotid intervention in severe carotid stenosis after an anterior circulation
ischemic event reduces the risk of further infarcts if the surgery is performed
soon after the incident event. At present, there is no recommendation to
differentiate among subtypes of anterior circulation infarcts or transient
ischemic events. However, evidence is mounting that demonstrates a difference in 
pathophysiology of lacunar and nonlacunar (large artery) infarcts. The natural
history of lacunar strokes is different from large artery infarcts for recurrence
and mortality. Stroke is a heterogenous disease and consideration needs to be
directed to manage different stroke subtypes differently. Lacunar infarcts mostly
do not arise from large artery atheromatous disease or by cardioembolic
phenomena, and there is a negative predictive value for severe carotid stenosis
in lacunar strokes. Thus, current evidence suggests that lacunar strokes may not 
warrant investigation for carotid stenosis.