Cavernous cerebral infarction is a common type of stroke, often due to cerebral small vessel disease. The effect of antiplatelet drugs as secondary prevention on lacunar cerebral infarction is unclear. Wang Jun t, Intensive Care Unit, First Hospital of Nanping City, China The study was a double-blind, multicenter trial that included 3020 patients with recent symptomatic lacunar stroke diagnosed by cranial magnetic resonance, who were randomized into a 75 mg daily clopidogrel versus placebo group, and both groups were given 325 mg of aspirin daily. The primary outcome time was any form of recurrent stroke, including ischemic stroke with intracranial hemorrhage. The mean age of the included patients was 63 years, of which 63% were male. The mean follow-up was 3.4 years, and the risk of recurrent stroke in the aspirin plus clopidogrel (dual antiplatelet therapy) treatment group (125 stroke patients in total, annual recurrence rate of 2.5%) was not significantly lower compared with the aspirin-alone group (138 stroke patients, annual recurrence rate of 2.7%) (hazard ratio 0.92, 95% confidence interval [CI], of 0.72 to 1.16), nor was there a significant reduction in the risk of recurrent ischemic (hazard ratio 0.82, 95% confidence interval CI 0.63 to 1.09), or of disabling or fatal stroke (hazard ratio 1.06, 95% confidence interval 0.69 to 1.64). However, the risk of major cerebral hemorrhage with dual antiplatelet therapy (105 cerebral hemorrhages with an annual incidence of 2.1%) was twice as high as that in the aspirin-alone group (56 cerebral hemorrhages with an annual recurrence rate of 1.1%) (hazard ratio 1.97, 95% confidence interval 1.41 to 2.71, P<0.001). Seventy-one percent (133 of 187) of recurrent ischemic strokes were classified as lacunar strokes. Mortality was higher in the dual antiplatelet therapy group (113 deaths) than in the aspirin-alone group (77 deaths) (hazard ratio 1.52,95% confidence interval 1.14 to 2.04, P=0.004), and the difference in mortality was not entirely due to major cerebral hemorrhage (9 deaths in the dual antiplatelet group versus 4 in the aspirin-alone group). In patients with recent lacunar stroke, dual antiplatelet therapy with clopidogrel plus aspirin did not significantly reduce stroke recurrence; rather, it significantly increased the risk of intracranial hemorrhage and death.