| New Recommendation | For patients with small vessel stroke, the preventive effect of cilostazol might be beneficial. | IIb | B |
| In the CSPS trial, which predominantly involved patients with lacunar stroke (74% of the participants), cilostazol was more effective than the placebo for secondary stroke prevention.191 In the CSPS II trial, compared with the aspirin group, the cilostazol group had a significantly reduced risk of the first occurrence of ischaemic or haemorrhagic stroke. The incidence of bleeding events was significantly reduced in the cilostazol group. However, subgroup analysis showed no significant reduction in recurrent stroke risk in participants with lacunar stroke.192
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| Reworded | Indiscriminate long-term dual antiplatelet therapy is not recommended for patients with small vessel stroke. | IIa | B |
| New Recommendation | For patients with small vessel stroke, if tolerated, it is recommended to lower systolic blood pressure to below 130 mmHg and diastolic blood pressure to below 80 mmHg. | IIa | B |
| The SPS3 trial enrolled 3020 patients with lacunar stroke and compared the effects of a systolic blood pressure target of<130 mmHg vs 130–149 mmHg on stroke recurrence and cognition. Although there was no statistically significant difference in stroke recurrence, the group with a systolic blood pressure target of<130 mmHg significantly reduced the incidence of cerebral haemorrhage.193
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