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This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.<\/jats:p>","DOI":"10.1177\/23969873231219416","type":"journal-article","created":{"date-parts":[[2024,2,21]],"date-time":"2024-02-21T07:01:35Z","timestamp":1708498895000},"page":"5-68","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":72,"title":["European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke"],"prefix":"10.1093","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9812-6642","authenticated-orcid":false,"given":"Joanna M","family":"Wardlaw","sequence":"first","affiliation":[{"name":"Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK 1"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8436-6074","authenticated-orcid":false,"given":"Hugues","family":"Chabriat","sequence":"additional","affiliation":[{"name":"CNVT and Department of Neurology, Hopital Lariboisi\u00e8re, Paris, France 2"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frank-Erik","family":"de Leeuw","sequence":"additional","affiliation":[{"name":"Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands 3"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8675-7968","authenticated-orcid":false,"given":"St\u00e9phanie","family":"Debette","sequence":"additional","affiliation":[{"name":"Bordeaux Population Health Research Center; University of Bordeaux \u2013 Inserm U1219; Bordeaux; Department of Neurology, Institute for Neurodegenerative Diseases, Bordeaux University Hospital, Bordeaux, France 4"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0654-387X","authenticated-orcid":false,"given":"Martin","family":"Dichgans","sequence":"additional","affiliation":[{"name":"Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Medical Center, Munich; Munich Cluster for Systems Neurology (SyNergy), Munich; German Center for Neurodegenerative Diseases (DZNE, Munich), Munich; German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany 5"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2769-3148","authenticated-orcid":false,"given":"Fergus","family":"Doubal","sequence":"additional","affiliation":[{"name":"Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor\u2019s Building, Edinburgh, UK 6"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7889-1120","authenticated-orcid":false,"given":"Hanna","family":"Jokinen","sequence":"additional","affiliation":[{"name":"Neurocenter, Helsinki University Hospital and University of Helsinki, HUS, Helsinki, Finland 7"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6359-0023","authenticated-orcid":false,"given":"Aristeidis H","family":"Katsanos","sequence":"additional","affiliation":[{"name":"Neurology, McMaster University & Population Health Research Institute, Hamilton, ON, Canada 8"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9501-4031","authenticated-orcid":false,"given":"Raffaele","family":"Ornello","sequence":"additional","affiliation":[{"name":"Neurology\/Department of Biotechnological ad Applied Clinical Sciences, University of L\u2019Aquila, L\u2019Aquila, Italy 9"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7357-8530","authenticated-orcid":false,"given":"Leonardo","family":"Pantoni","sequence":"additional","affiliation":[{"name":"Neurology and Stroke Unit, Luigi Sacco Hospital, Milan, Italy 10"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9976-2459","authenticated-orcid":false,"given":"Marco","family":"Pasi","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Tours, Tours, France 11"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5987-9828","authenticated-orcid":false,"given":"Aleksandra M","family":"Pavlovic","sequence":"additional","affiliation":[{"name":"University of Belgrade, Faculty of Special Education and Rehabilitation, Belgrade, Serbia 12"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8775-6884","authenticated-orcid":false,"given":"Salvatore","family":"Rudilosso","sequence":"additional","affiliation":[{"name":"Comprehensive Stroke Center, Department of Neurology, Hospital Cl\u00ednic of Barcelona, Barcelona, Spain 13"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Reinhold","family":"Schmidt","sequence":"additional","affiliation":[{"name":"Department of Neurology, Medical University Graz, Graz, Austria 14"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9502-6937","authenticated-orcid":false,"given":"Julie","family":"Staals","sequence":"additional","affiliation":[{"name":"Department of Neurology and CARIM School for cardiovascular diseases, MUMC+, Maastricht, The Netherlands 15"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3027-5369","authenticated-orcid":false,"given":"Martin","family":"Taylor-Rowan","sequence":"additional","affiliation":[{"name":"School of Health and Wellbeing; 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