A Non-linear Association Between Total Small Vessel Disease Score and Hemorrhagic Transformation After Ischemic Stroke With Atrial Fibrillation and/or Rheumatic Heart Disease

Abstract

Background: Previous studies have investigated the association between a single marker of cerebral small vessel disease (SVD) and hemorrhagic transformation (HT). However, the effect of the total SVD burden on HT has not been evaluated yet. We aimed to investigate the association between the total SVD score and HT in ischemic stroke patients with atrial fibrillation (AF) and/or rheumatic heart disease (RHD). Methods: Ischemic stroke patients with AF and/or RHD admitted within 7 days after onset were enrolled at two hospitals in China. The total SVD score was based on the presence of lacunes, extensive white matter hyperintensities, cerebral microbleeds, and moderate to severe enlarged perivascular spaces in the basal ganglia. One point was awarded for the presence of each marker, with the total SVD score ranging from 0 to 4 points. HT was assessed based on follow-up imaging scans during hospitalization and was classified according to the radiographic appearance and associated neurological deterioration. Results: Of 207 enrolled patients (mean age, 67.79 years; 58.9% female), 89 (43.0%) developed HT. The distribution of the total SVD score was significantly different between patients with and without HT in the univariate analysis ( p = 0.04). After adjustment for confounders, a SVD score of 1 was independently associated with an increased risk of HT [odds ratio (OR), 3.23; 95% confidence interval (CI), 1.48–7.04; p = 0.003], while a SVD score ≥2 was inversely related to the occurrence of HT (OR, 0.41; 95% CI, 0.19–0.91; p = 0.03). These independent associations remained significant in the subgroups of hemorrhagic infarction and asymptomatic HT (all p < 0.05). Conclusions: In our study, the relationship between the total SVD score and HT was not linear, since the presence of only one marker of SVD was associated with an increased risk of HT, while the presence of two or more markers of SVD was a potential protective factor for HT. These results indicate the need to take the total SVD score into account, not only a single SVD marker, when assessing the risk of HT. Further studies with larger samples are required to validate these findings.

Extent of white matter lesion is associated with early hemorrhagic transformation in acute ischemic stroke related to atrial fibrillation

“…In previous studies, the proportion of stroke patients with HT varied largely between 50.81% (Wei et al, 2019) and 5.9% (Valentino et al, 2017) in the literature. Difference in the time interval between stroke onset, in the modality of follow-up imaging and in the population of stroke patients included in the studies partially explains the discrepancies between the reported different rates.…”

“…In both studies, the majority of strokes were classified as noncardioembolic. Conversely, another retrospective study of 207 patients presenting with acute stroke and AF and/or rheumatic heart disease evaluated with brain MRI or CT scan up to 7 days after admission supported a potential role for leukoaraiosis in predicting HT after acute ischemic stroke (Wei et al., 2019). Moreover, Bivard et al.…”

“…Early hemorrhagic transformation (HT) of the infarct occurs in 5.9% (Valentino et al., 2017) to 50.81% (Wei et. et al., 2019) of patients with acute ischemic stroke. The risk of HT is influenced by age (Marsh et al., 2013), presence of large infarct (Kablau et al., 2011; Muscari et al., 2020; Paciaroni et al., 2018), use of anticoagulants before the stroke (Pande et al., 2020), severe neurologic deficit (Kidwell et al., 2002), congestive heart failure (Paciaroni et al., 2018), hyperglycemia (Muscari et al., 2020), renal impairment (Marsh et al., 2013), low platelet count (Prodan et al., 2010), elevated systolic blood pressure (Álvarez‐Sabín et al., 2013) and use of reperfusion therapies (Zhang et al., 2014).…”

Association between Deep Medullary Veins in the Unaffected Hemisphere and Functional Outcome in Acute Cardioembolic Stroke: An Observational Retrospective Study

“…The scanning sequences included SWI, fluid-attenuated inversion recovery (FLAIR) imaging, T1-weighted imaging, T2-weighted imaging, and diffusion-weighted imaging (DWI). Detailed MRI parameters have been described in our previous studies [ 31 , 32 ].…”

“…Hemorrhagic transformation (HT) was defined as hemorrhage within the infarct territory or parenchyma hemorrhage outside the infarct lesion that was detected on follow-up CT or MRI during hospitalization, but not on head CT on admission [ 33 ]. As in our previous studies [ 31 , 32 , 34 ], we further divided HT into hemorrhagic infarction (HI), parenchymal hemorrhage (PH) based on the criteria of radiographic appearance [ 35 ], and symptomatic HT (sHT) on neurological symptoms [ 36 ]. Large hemispheric infarction was recorded when the infarct area was larger than 1/2 of the blood supply area of the middle cerebral artery (MCA) on FLAIR and/or DWI [ 37 , 38 ].…”