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. More research is needed to develop and test disease-specific treatments for secondary stroke prevention after small vessel stroke. We focus here on clinical ischemic stroke related to small vessel disease, not on silent small vessel disease, which was reviewed in a 2017 scientific statement.418 Recommendation-Specific Supportive Text 1. Cilostazol has been studied as an alternative to aspirin therapy for ischemic stroke related to small vessel disease. In the CSPS trial (Cilostazol for Prevention of Secondary Stroke), cilostazol was compared with placebo in 1095 Japanese patients with noncardioembolic ischemic stroke There was a sig- nificant reduction in the risk of recurrent stroke in the cilostazol treatment group and in partici- pants with lacunar stroke in the subgroup analy- sis. 