Background: Lacunar stroke accounts for a quarter of all acute ischemic infarction. Insufficient information is available with respect to the pattern and risk factor profiles of patients with lacunar stroke from developing countries. We undertook this study to define the clinical features, imaging characteristics, and risk factors in a group of patients with image proven lacunar stroke from southern India, and contrast them with those described from developed countries. Methods: We retrospectively reviewed the demographic, risk factor profiles (presence of hypertension, diabetes mellitus, dyslipidemia, smoking) and CT/MRI brain findings (microbleeds, small vessel ischemic changes, old infarcts) and CV Doppler/CT or MR angiography of brain and neck vessels of 132 consecutive patients diagnosed with image proven acute infarct measuring 2-20mm in subcortical white matter, basal ganglia, thalamus or pons, presumed to result from the occlusion of a single small perforating artery(lacunar infarct), in Department of Neurology, Kasturba Medical College, Manipal, Karnataka, India. Results: Males comprised 63.6%, with 56% between the ages of 55-75 years. Hypertension was present in 98 (74.2%) and 50 (37.8%) had diabetes mellitus. Pure motor hemiparesis was the most common clinical syndrome 79 (59.8%), followed by ataxic hemiparesis in 32 (24.2%). Chronic lacunar infarct was detected in 68 (51.5%) patients MRI; however, past history of stroke was present only in 10 (7.6%). Small vessel ischemic changes were present in 100 (75.8%), and cerebral micro-bleeds in 10 (7.6%) patients. Angiography showed symptomatic side carotid stenosis of over 50% in 6 (4.5%), intracranial major vessel stenosis in 12.61% of patients. Conclusion: Lacunar stroke, although less dramatic in its clinical presentation, is frequently associated with modifiable risk factors like hypertension and diabetes. It should be regarded as a warning sign of underlying diffuse small vessel disease; hence, portends recurrent stroke and vascular dementia. Our findings are in accordance with most studies from developed countries.