Diffusion-weighted imaging lesions and risk of recurrent stroke after intracerebral haemorrhage

Abstract

ObjectiveTo determine whether the presence of diffusion-weighted imaging-positive (DWI+) lesions is associated with recurrent stroke after intracerebral haemorrhage (ICH).MethodsThe REstart or STop Antithrombotics Randomised Trial (RESTART) assessed the effect of restarting versus avoiding antiplatelet therapy after ICH on major vascular events for up to 5 years. We rated DWI sequences of MRI done before randomisation for DWI+ lesion presence, masked to outcome and antiplatelet use. Cox proportional hazards regression models were used to quantify associations.ResultsOf 537 participants in RESTART, 247 (median (IQR) age 75.7 (69.6–81.1) years; 170 men (68.8%); 120 started vs 127 avoided antiplatelet therapy) had DWI sequences on brain MRI at a median of 57 days (IQR 19–103) after ICH, of whom 73 (30%) had one or more DWI+ lesion. During a median follow-up of 2 years (1–3), 18 participants had recurrent ICH and 21 had ischaemic stroke. DWI+ lesion presence was associated with all stroke, (adjusted HR 2.2 (95% CI 1.1 to 4.2)) and recurrent ICH (4.8 (95% CI 1.8 to 13.2)), but not ischaemic stroke (0.9 (95% CI 0.3 to 2.5)). DWI+ lesion presence (0.5 (95% CI 0.2 to 1.3)) vs absence (0.6 (95% CI 0.3 to 1.5), pinteraction=0.66) did not modify the effect of antiplatelet therapy on a composite outcome of recurrent stroke.ConclusionsDWI+ lesion presence in ICH survivors is associated with recurrent ICH, but not with ischaemic stroke. We found no evidence of modification of effects of antiplatelet therapy on recurrent stroke after ICH by DWI+ lesion presence. These findings provide a new perspective on the significance of DWI+ lesions, which may be markers of microvascular mechanisms associated with recurrent ICH.Trial registration numberISRCTN71907627.

Cardiovascular Events After Intracerebral Hemorrhage

“…A contemporary study of ICH patients enrolled in the RESTART (Restart or Stop Antithrombotics Randomized Trial) found that a DWI lesion was associated with all stroke (aHR, 2.2 [95% CI, 1.1–4.2]) and recurrent ICH (aHR, 4.8 [95% CI, 1.8–13.2]) but not ischemic stroke. 51 Both studies, however, were limited by few outcome events that precluded adequate adjustment of covariates. Nevertheless, DWI lesions offer an insight into the microvascular mechanisms associated with recurrent cerebrovascular disease.…”

Diffusion-weighted imaging-based radiomics for predicting 1-year ischemic stroke recurrence

“…A previous study also demonstrated that less antiplatelet at discharge was associated with a higher recurrence rate ( 20 ). Another study showed that there was no evidence of heterogeneity in the effects of antiplatelet therapy by the presence of DWI-positive infarctions vs. absence on the risk of any recurrent stroke ( 19 ). Patients with non-recurrence and recurrent strokes did not have significantly different antiplatelet levels, which may be related to the disease's heterogeneity ( 14 ).…”

“…Stroke may present with or without underlying arterial pathologies because of the heterogeneity of stroke ( 14 ). Recent research demonstrated that lesions on DWI were indicators of microvascular occlusive events that were predisposing to microvessel rupture ( 19 ).…”

“…Magnetic resonance imaging (MRI) plays an important role in the diagnosis and prognosis of ischemic stroke. However, few studies focused on ischemic stroke lesions based on imaging in predicting stroke recurrence ( 19 , 20 ). Only a few low-order features of diffusion-weighted imaging (DWI), such as lesion number and presence of lesions, were assessed.…”

Cerebral Small-Vessel Diseases: A Look Back from 1991 to Today

“…Systematic MRI studies also revealed that such lesions, not associated with neurological deficits, were often visible remote to the site of acute ICH [14]. While this finding was initially thought to be related to the underlying cause of ICH, and even sometime suggestive of infectious endocarditis, it was finally shown that the presence of such alterations was in fact related to the actual severity, cause, and pathophysiology of the underlying cSVD [15]. A number of questions remain as to why some of these lesions are associated with stroke symptoms while others are not.…”