Patient handout

Small-Vessel (Lacunar) Stroke (TOAST SVO)

PRODUCTION

1. Your condition

This handout is for small-vessel (lacunar) stroke (toast svo). Your care team identified this based on: classic lacunar syndrome — pure motor hemiparesis (fisher 1965; aha/asa 2021).

Other reasons your team may use this plan: pure sensory stroke (thalamic vpl lesion; fisher 1965); ataxic hemiparesis (corona radiata / pons; fisher 1965); sensorimotor stroke (internal capsule + thalamus border; fisher 1965).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
aspirin	162-325 mg loading once, then 81 mg PO daily lifelong	PO	load + daily	SPS3 antiplatelet arm (Benavente NEJM 2012 PMID 22929185) — chronic aspirin alone reduces recurrence; DAPT increased bleeding without benefit; AHA/ASA 2021 lifelong aspirin
clopidogrel	75 mg PO daily	PO	once daily	Alternative monotherapy if aspirin intolerant (CAPRIE; AHA/ASA 2021); still NOT in combination chronically per SPS3

Plan: SVO (lacunar) secondary prevention: aspirin alone (no chronic DAPT) + intensive BP control (SBP <130) + high-intensity statin + glycemic + smoking cessation (AHA/ASA 2021; SPS3 PMID 23910302)

3. When to call your provider

Contact your care team if any of the following happen:

New TIA / focal deficit → ED
BP >130 SBP on 3-drug regimen → resistant HTN workup (cardio.htn.resistant.v1)
MoCA declining → vascular cognitive impairment workup; route to neuro.vascular-dementia.v1
LDL >55-70 on max statin → ezetimibe + PCSK9i
Recurrent SVO on aspirin → cilostazol add-on
New lobar CMBs on follow-up MRI → CAA pathway, reconsider antiplatelet

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

SVO with HTN as dominant RF — lipohyalinosis of perforator arterioles; aggressive BP control SBP <130 (SPS3 PMID 23910302)
SVO with DM as dominant RF — microvascular disease driver; HbA1c <7% with metformin + SGLT2i if ASCVD/CKD/HF (ADA 2026; AHA/ASA 2021)
SVO with active tobacco use — accelerates SVD; cessation pharmacotherapy mandatory (AHA/ASA 2021 Class I)
CAA overlap with multiple lobar microbleeds + cortical superficial siderosis (Boston Criteria v2.0) — caution antiplatelet for ICH risk
CADASIL NOTCH3 — familial small-vessel disease with migraine with aura + early SVO + leukoencephalopathy + characteristic anterior temporal pole T2 hyperintensities
Binswanger pattern — progressive subcortical leukoencephalopathy with cognitive + gait + bladder symptoms; extreme Fazekas burden + multiple lacunes (Binswanger 1894; modern criteria 2015)

5. Follow-up

Stroke clinic 7-14 d + 90 d + 12 mo: SBP <130, LDL <55-70, HbA1c <7%, smoking cessation, aspirin adherence, vascular cognitive screen, OSA screen, MIND diet (AHA/ASA 2021)

6. Sources

Guideline: 2021 AHA/ASA Secondary Prevention + 2025 AHA/ACC HTN + 2026 ACC/AHA Dyslipidemia + ADA 2026 + AHA/ASA VCI 2019