Antiplatelet Therapy in Cerebral Small Vessel Disease

We critically evaluate the evidence for the use of antiplatelet therapy for stroke prevention following lacunar stroke and in patients with hemorrhage-prone cerebral small vessel disease.

Pooled lacunar stroke subgroup analyses of all relevant randomized controlled trials to date suggest a 22% relative risk reduction in recurrent stroke by single antiplatelet therapy (RR 0.77, 95% CI 0.62-0.97) compared with placebo, no consistent suggestion of variable efficacy amongst specific antiplatelet agents, and the absence of clear benefit with dual over single antiplatelet therapy. Current data does not support withholding antiplatelet therapy where otherwise indicated in patients with cerebral microbleeds on MRI or those who have suffered intracerebral hemorrhage. Antiplatelet monotherapy appears to provide persistent secondary stroke prevention in patients with lacunar stroke. Whether phosphodiesterase inhibitors, particularly cilostazol, provide additional advantage in patients with cerebral small vessel disease is worthy of further investigation.