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Background and purpose: Hypertension is the most prevalent risk factor for acute and chronic cerebrovascular disease. As patients with resistant hypertension are a subgroup with even higher risk, we aimed to evaluate the burden of microangiopatic disease and functional outcome in subjects with stroke and difficult to treat hypertension.Design and method: acute ischemic stroke patients were prospectively included in a multidisciplinary secondary stroke prevention program. Pre-stroke vascular risk factor profile and control were obtained from electronic medical records and chronic vascular disease burden was assessed on admission MRI. Functional and cognitive evaluation were performed one-month after stroke.Results: 1327 patients (16% with resistant hypertension) were included from September 2009 and December 2015. Patients with resistant hypertension were older (80±8 vs 77±10, p 0.0004), with higher prevalence of obesity (62% vs 50%, p 0.001), metabolic syndrome (52% vs 38%, p 0.0001) and history of atrial fibrillation (27% vs 16%, p 0.0001). There was a direct relationship between resistant hypertension and the severity of chronic microvascular lesions, and also with functional and cognitive outcomes (table).Conclusion: Hypertension increases vascular events risk, even more in the setting of resistant hypertension. Requirement of a therapeutic strategy involving combination of multiple drugs generally indicates more severe underlying hypertensive disease. It is possible that mechanisms of endothelial dysfunction responsible of the neurovascular unit damage might remain active despite achieving blood pressure target.