Lacunar ischemic lesions are related to a pathology involving perforators, due to direct changes in the arteries or to an indirect mechanism, such as cardiac or artery to artery embolism, or to hypoperfusion in cases of cardiac failure, or proximal occlusion of large arteries. Changes involving the large intracranial arteries have progressively been taken into consideration as a cause of the disease. This latter aspect is interesting since possible endovascular treatment can be proposed in selected cases. In patients with lacunar syndrome an extended clinical and neuroradiological approach is indicated to choose the most appropriate therapy. Not all lesions recognizable on CT/MR are the expressions of ischemic lesions, this is another important aspect that should be considered in the differential diagnosis.