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neuro.stroke-svo.v1PRODUCTION
neuro.stroke-svo.v1

Small-Vessel (Lacunar) Stroke (TOAST SVO)

neurologyacutechronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Detailed

Ischemic stroke with SVO (lacunar) mechanism — subcortical infarct <15 mm, classic lacunar syndrome, exclusion of LAA + CE sources (Adams Stroke 1993; AHA/ASA 2021)

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SVO mechanism flagged or being investigated

Patient inputs (16)

Age stratifies CADASIL suspicion (early-onset <60) vs sporadic SVO; affects bleed risk on aspirin

CKD frequently coexists with HTN-SVO; eGFR informs medication dosing

HTN is dominant SVO risk factor (lipohyalinosis of perforator arterioles); aggressive BP control reduces recurrence (SPS3)

DM drives microvascular disease; HbA1c control reduces SVO recurrence (ADA 2026)

Smoking accelerates SVO; cessation pharmacotherapy AHA/ASA 2021 Class I

Classic Fisher syndromes (pure motor / pure sensory / ataxic-hemiparesis / sensorimotor / dysarthria-clumsy-hand) support SVO mechanism (AHA/ASA 2021)

High-intensity statin LDL <70-100 per SVO baseline; ASCVD risk overlap (SPARCL Amarenco NEJM 2006 PMID 16899775; 2026 ACC/AHA Lipid)

DM is major SVO driver; HbA1c <7% target (ADA 2026; AHA/ASA 2021)

DWI confirms acute small subcortical infarct <15 mm in perforator territory (TOAST SVO criterion)

SWI / T2* identifies cerebral microbleeds (CMBs) — deep CMBs = HTN-SVO; lobar CMBs = CAA overlap (Boston Criteria v2.0)

FLAIR for white-matter hyperintensities (WMH) Fazekas grading; leukoaraiosis burden predicts cognitive trajectory

Exclude large-artery atherosclerosis and intracranial atherosclerosis (TOAST exclusion criterion for SVO)

Exclude AF as cardioembolic source (TOAST exclusion criterion for SVO)

SPS3 (Benavente NEJM 2013 PMID 23910302) — SBP <130 reduces recurrent stroke in lacunar; SPRINT-MIND (Williamson JAMA 2019 PMID 28771346) — lower SBP improves cognitive trajectory

Antiplatelet decision impacted by CMB count / CAA overlap (lobar microbleeds caution); SPS3 — avoid chronic DAPT for lacunar

Family history of migraine + early SVO + leukoencephalopathy → CADASIL NOTCH3 suspicion

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationalseveresvo_with_hypertension_predominant
    SVO with HTN as dominant RF — lipohyalinosis of perforator arterioles; aggressive BP control SBP <130 (SPS3 PMID 23910302)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresvo_with_diabetes_predominant
    SVO with DM as dominant RF — microvascular disease driver; HbA1c <7% with metformin + SGLT2i if ASCVD/CKD/HF (ADA 2026; AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresvo_with_smoking_predominant
    SVO with active tobacco use — accelerates SVD; cessation pharmacotherapy mandatory (AHA/ASA 2021 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecerebral_amyloid_angiopathy_overlap_microbleeds
    CAA overlap with multiple lobar microbleeds + cortical superficial siderosis (Boston Criteria v2.0) — caution antiplatelet for ICH risk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecadasil_notch3_familial_svo
    CADASIL NOTCH3 — familial small-vessel disease with migraine with aura + early SVO + leukoencephalopathy + characteristic anterior temporal pole T2 hyperintensities
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebinswanger_chronic_progressive
    Binswanger pattern — progressive subcortical leukoencephalopathy with cognitive + gait + bladder symptoms; extreme Fazekas burden + multiple lacunes (Binswanger 1894; modern criteria 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateclassic_lacunar_pure_motor_or_pure_sensory_or_ataxic_hemiparesis
    Classic lacunar syndrome — pure motor / pure sensory / ataxic-hemiparesis / sensorimotor / dysarthria-clumsy-hand (Fisher 1965; AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesubcortical_infarct_lt_15mm_imaging
    Subcortical infarct <15 mm in perforator territory on MRI DWI (TOAST SVO criterion Adams Stroke 1993)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesps3_bp_target_lt_130_80
    SPS3 lower BP target SBP <130 reduces recurrent stroke in lacunar (Benavente NEJM 2013 PMID 23910302)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatevascular_cognitive_impairment_post_svo
    Vascular cognitive impairment after SVO event — MoCA <26 + WMH progression on MRI; route long-term cognitive Rx to neuro.vascular-dementia.v1 (AHA/ASA VCI 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

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)
axis: svo_secondary_preventionstep 1 - Step 1 — Aspirin 81 mg daily ALONE (SPS3 PMID 22929185 — chronic DAPT INCREASED bleeding WITHOUT benefit in lacunar)
Selected step "Step 1 — Aspirin 81 mg daily ALONE (SPS3 PMID 22929185 — chronic DAPT INCREASED bleeding WITHOUT benefit in lacunar)" — All confirmed lacunar (SVO) stroke patients; CAA overlap caution (shared-decision per CMB burden)
  • aspirin
    first line
    antiplatelet_COX1
    162-325 mg loading once, then 81 mg PO daily lifelong • PO • load + daily
    triggers: svo_confirmed, no_caa_with_multiple_lobar_cmb, no_anticoag_indication
    SPS3 antiplatelet arm (Benavente NEJM 2012 PMID 22929185) — chronic aspirin alone reduces recurrence; DAPT increased bleeding without benefit; AHA/ASA 2021 lifelong aspirin
    rxcui 1191
  • clopidogrel
    second line
    antiplatelet_P2Y12
    75 mg PO daily • PO • once daily
    triggers: aspirin_allergy, aspirin_intolerance
    Alternative monotherapy if aspirin intolerant (CAPRIE; AHA/ASA 2021); still NOT in combination chronically per SPS3
    rxcui 32968

outpatient playbook — drug actions (6)

  1. 1. aspirin 81 mg daily (lifelong; NOT chronic DAPT)
    81 mg PO daily • PO • once daily
    trigger: All SVO patients
    SPS3 PMID 22929185 — DAPT chronic was harmful in lacunar; AHA/ASA 2021 single antiplatelet
  2. 2. atorvastatin
    80 mg PO daily • PO • once daily
    trigger: LDL ≥55-70
    2026 ACC/AHA Lipid
  3. 3. lisinopril ± chlorthalidone ± amlodipine (target SBP <130)
    Per BP target • PO • daily
    trigger: SBP ≥130
    SPS3 PMID 23910302; 2025 AHA/ACC HTN
  4. 4. metformin ± SGLT2i
    Per glycemic target • PO • BID / daily
    trigger: HbA1c ≥7%
    ADA 2026
  5. 5. varenicline / NRT / bupropion
    Per agent • PO / patch / lozenge • per agent
    trigger: Active tobacco
    AHA/ASA 2021 Class I
  6. 6. cilostazol (refractory)
    100 mg PO BID • PO • BID
    trigger: Recurrent SVO on aspirin alone
    CSPS.com — antiplatelet add-on for non-cardioembolic stroke

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Classic lacunar syndrome — pure motor hemiparesis (Fisher 1965; AHA/ASA 2021); Pure sensory stroke (thalamic VPL lesion; Fisher 1965); Ataxic hemiparesis (corona radiata / pons; Fisher 1965).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Small-Vessel (Lacunar) Stroke (TOAST SVO)** (neuro.stroke-svo.v1).
Phenotype framing: SVO sub-phenotype: HTN-predominant / DM-predominant / smoking-predominant / CAA-overlap / CADASIL / Binswanger chronic leukoencephalopathy / strategic-infarct dementia (AHA/ASA 2021)
Scope: Ischemic stroke with SVO (lacunar) mechanism — subcortical infarct <15 mm, classic lacunar syndrome, exclusion of LAA + CE sources (Adams Stroke 1993; AHA/ASA 2021)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)** — step "Step 1 — Aspirin 81 mg daily ALONE (SPS3 PMID 22929185 — chronic DAPT INCREASED bleeding WITHOUT benefit in lacunar)".
1. aspirin 162-325 mg loading once, then 81 mg PO daily lifelong PO load + daily (antiplatelet_COX1, first line) — SPS3 antiplatelet arm (Benavente NEJM 2012 PMID 22929185) — chronic aspirin alone reduces recurrence; DAPT increased bleeding without benefit; AHA/ASA 2021 lifelong aspirin
2. clopidogrel 75 mg PO daily PO once daily (antiplatelet_P2Y12, second line) — Alternative monotherapy if aspirin intolerant (CAPRIE; AHA/ASA 2021); still NOT in combination chronically per SPS3

Setting playbook (outpatient) — Stroke + cognitive clinic 7-14 d + 90 d + 12 mo: SBP <130, LDL <55-70, HbA1c <7%, smoking cessation, aspirin adherence, annual MoCA for vascular cognitive impairment, OSA screen, MIND diet (AHA/ASA 2021; SPS3)
3. aspirin 81 mg daily (lifelong; NOT chronic DAPT) 81 mg PO daily PO once daily — All SVO patients (SPS3 PMID 22929185 — DAPT chronic was harmful in lacunar; AHA/ASA 2021 single antiplatelet)
4. atorvastatin 80 mg PO daily PO once daily — LDL ≥55-70 (2026 ACC/AHA Lipid)
5. lisinopril ± chlorthalidone ± amlodipine (target SBP <130) Per BP target PO daily — SBP ≥130 (SPS3 PMID 23910302; 2025 AHA/ACC HTN)
6. metformin ± SGLT2i Per glycemic target PO BID / daily — HbA1c ≥7% (ADA 2026)
7. varenicline / NRT / bupropion Per agent PO / patch / lozenge per agent — Active tobacco (AHA/ASA 2021 Class I)
8. cilostazol (refractory) 100 mg PO BID PO BID — Recurrent SVO on aspirin alone (CSPS.com — antiplatelet add-on for non-cardioembolic stroke)

Non-pharmacologic actions:
- AHA "Get With The Guidelines" outcome documentation
- Recurrent-stroke counselling — any focal deficit = 911
- Sleep study if STOP-BANG ≥3
- MIND / Mediterranean diet (cognitive benefit signal)
- Aerobic exercise 150 min/wk moderate intensity
- CADASIL genetic counselling for family members if NOTCH3 positive
- Vascular cognitive impairment / VaD evaluation if MoCA declining

AVOID / contraindication checks:
- AVOID_chronic_DAPT_for_lacunar_secondary_prevention (SPS3 antiplatelet arm — increased bleeding without benefit; PMID 22929185)
- CAA_overlap_with_multiple_lobar_CMBs_caution_antiplatelet (Boston Criteria v2.0)
- NO_DOAC_for_SVO_unless_AF_or_other_cardioembolic_source (NAVIGATE ESUS, COMPASS CKD show no benefit for ESUS / non CE stroke)
- CADASIL_avoid_thrombolysis_if_possible_due_to_microbleed_burden (case series only; shared decision)
- Cilostazol_contraindicated_in_HF_NYHA_III_IV
- High_intensity_statin_baseline_LFTs_repeat_at_4 6wk
- SBP_target_<130_per_SPS3_not_<120 (perfusion pressure concerns in severe SVD)
- Varenicline_caution_in_severe_psych_history (AHA/ASA 2021)

Monitoring

Regimen monitoring:
- BP home log + clinic q3 mo until <130 SBP; then q6 mo (SPS3 PMID 23910302; 2025 AHA/ACC HTN)
- LDL at 4-6 wk after statin start; q6-12 mo (target <55-70 per 2026 ACC/AHA Lipid)
- HbA1c q3 mo if DM until <7%, then q6 mo (ADA 2026)
- Annual MoCA for vascular cognitive impairment screen (AHA/ASA 2021)
- Annual neuro exam for new lacunar events
- Repeat MRI SWI if recurrent symptoms — track new CMBs for CAA progression
- CK + LFT 4-6 wk after statin start
- Smoking status every visit + reinforcement
- Sleep study if STOP-BANG ≥3 (AHA/ASA 2021)

Setting (outpatient) monitoring:
- Clinic 7-14 d for medication reconciliation
- Stroke clinic 90 d + 12 mo
- BP home log + clinic q3 mo (target SBP <130 per SPS3)
- LDL at 4-6 wk after statin then q6-12 mo
- HbA1c q3 mo until controlled then q6 mo
- Annual MoCA
- PHQ-9 at 90 d, 6 mo, 12 mo

Follow-up plan: 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)
- Close-out criterion: Secondary prevention bundle on board + cognitive screen scheduled

Monitoring phase: BP home log + clinic; HbA1c q3 mo; vascular cognitive impairment annual MoCA; repeat MRI for new CMBs if recurrent symptoms (AHA/ASA 2021)

Disposition

Current setting: outpatient — Stroke + cognitive clinic 7-14 d + 90 d + 12 mo: SBP <130, LDL <55-70, HbA1c <7%, smoking cessation, aspirin adherence, annual MoCA for vascular cognitive impairment, OSA screen, MIND diet (AHA/ASA 2021; SPS3)

Disposition criteria:
- Continue lifelong aspirin + intensive BP + statin (AHA/ASA 2021)
- Transition to community exercise programs at 6-12 mo per functional status

Escalation triggers (move to higher acuity):
- 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

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] SVO with HTN as dominant RF — lipohyalinosis of perforator arterioles; aggressive BP control SBP <130 (SPS3 PMID 23910302)
- [SEVERE] SVO with DM as dominant RF — microvascular disease driver; HbA1c <7% with metformin + SGLT2i if ASCVD/CKD/HF (ADA 2026; AHA/ASA 2021)
- [SEVERE] SVO with active tobacco use — accelerates SVD; cessation pharmacotherapy mandatory (AHA/ASA 2021 Class I)

Citations

- 2021 AHA/ASA Secondary Prevention + 2025 AHA/ACC HTN + 2026 ACC/AHA Dyslipidemia + ADA 2026 + AHA/ASA VCI 2019 [PMID:34024117](https://pubmed.ncbi.nlm.nih.gov/34024117/)
- Cited evidence (PMID 23910302) [PMID:23910302](https://pubmed.ncbi.nlm.nih.gov/23910302/)
- Cited evidence (PMID 28771346) [PMID:28771346](https://pubmed.ncbi.nlm.nih.gov/28771346/)
- Cited evidence (PMID 22929185) [PMID:22929185](https://pubmed.ncbi.nlm.nih.gov/22929185/)
- Cited evidence (PMID 11589932) [PMID:11589932](https://pubmed.ncbi.nlm.nih.gov/11589932/)

Last reconciled with current guidelines: 2026-05-15.
References