Cerebral infarction related to small vessel disease, known as lacunar stroke, is strongly associated with hypertension (HTN). Numerous clinical trials have confirmed that control of HTN provides substantial stroke reduction overall (40%), without specifically distinguishing the effects on lacunar stroke.

The Secondary Prevention of Small Subcortical Strokes trial compared two levels of systolic blood pressure (SBP) among patients with a recent MRI-confirmed lacunar stroke for impact on recurrent stroke. Because of concern that excessive SBP lowering in the face of acute cerebral ischemia might be detrimental, subjects were randomized at least 2 weeks after the identifying event. Subjects (n = 3020) were randomized to one of two groups: SBP goal 130-149 mmHg or SBP goal < 130 mmHg. Clinicians were allowed to use whatever medications they preferred to attain SBP goals.

At 3.7 years, there was no statistically significant difference in the primary outcome of the study: all stroke. On the other hand, a secondary endpoint (which must be considered “hypothesis generating” since the primary endpoint failed) of hemorrhagic stroke was reduced by almost two-thirds in the SBP < 130 group. This finding prompted the consideration by the authors that since there was no difference in overall outcomes, but the suggestion of substantial reduction in hemorrhagic stroke by more strict blood pressure control, some clinicians might consider the more stringent SBP at least potentially beneficial.