Consideration should therefore also be given to com- prehensive, adjudicated long-term registries as an alternative means of investigation. Future investigations should have the following aims: To better understand the natural history of moy- amoya disease, including ethnic and geographic variability. To examine the efficacy of medical management options, including antiplatelet therapy and antico- agulation, with or without surgical intervention for ischemic moyamoya disease. To determine the most effective surgical interven- tion for moyamoya disease. To establish the optimal timing for surgical interven- tion after an acute clinical event in a patient with moyamoya disease. 5.3. Ischemic Stroke Caused by Small Vessel Disease Recommendation for Small Vessel Stroke Referenced studies that support the recommendation are summarized in online Data Supplement 31. COR LOE Recommendation In patients with ischemic stroke related to small vessel disease, the usefulness of cilostazol for secondary stroke prevention is Synopsis Cerebral small vessel disease represents a common pathogenetic mechanism for ischemic stroke, accounting This ischemic stroke sub- type is characterized by subcortical infarcts of <15 mm in diameter or lacunes in patients often presenting with lacunar stroke syndromes.38 Hypertension and diabe- tes are the most commonly recognized risk factors for small vessel disease.38,412 Although the risk of mortality is lower after small vessel stroke compared with other stroke types, the 1-year recurrence risk is estimated at Furthermore, small vessel disease and lacunar strokes are a leading cause of vascular dementia and vascular cognitive impairment.414,415 Prior investigative studies have assessed the impact of BP control and antiplatelet therapy on stroke recurrence after stroke related to small vessel disease.382,408,416,417 These studies support the general guidance for the use of antiplatelet therapy and BP recommendations refer- enced in relevant sections of this report. 