Do Imaging Markers of Cerebral Small Vessel Disease Predict Hematoma Volume and Outcome in Acute Intracerebral Hemorrhage?

Abstract

Background and Purpose: Cerebral small vessel disease (CSVD) markers have not been widely studied in relation to hematoma volume and growth in hypertensive intracerebral hemorrhage (ICH). The objectives to assess the relationship of white matter hyperintense lesions (WMHL), microbleeds (MBs), and cortical siderosis (CSS) with hematoma volume, hematoma expansion (HE), and 3 months outcome in patients with hypertensive ICH. Methods: All consecutive acute hypertensive supratentorial ICH presenting to the emergency were prospectively recruited. Baseline and 24 hours computed tomography (CT) to assess hematoma volume and magnetic resonance imaging (MRI) for CSVD markers were performed in all subjects. WMHL (graded using Fazekas's scale), MBs, and CSS were assessed and compared with baseline variables and outcomes. All the images were assessed by an experienced stroke neurologist/neuroradiologist. Results: One hundred and fifty-seven patients were screened and 60 were included. Mean age was 54.08 ± 11.57 years and 47 (78%) were males. Of 60, 19 (28.1%) had HE, 31 (51.6%) had major bleed (>30 ml), and 28 (47.46%) had poor 3 month outcome (mRS 4-6). On univariate analysis, high grade WMHL was associated with greater HE [odds ratio (OR): 2.65, confidence interval (CI) 1.48–4.72, P = 0.001), greater proportion with volume >30 ml (OR: 7.16, CI: 1.09–47.13, P = 0.001) and poor outcome (OR: 2.1, CI: 0.05–3.27, P = 0.001). MBs were associated with poor outcome (P = 0.029) but not with HE/volume. CSS was related to HE (P = 0.031), a large volume bleed (P = 0.023), and poor outcome (P = 0.021). On multivariate model, only WMHL independently predicted HE (P = 0.034), greater proportion with bleed volume >30 ml (P = 0.041), and poor outcome (P = 0.042). Conclusions: WMHL in MRI serves as a predictor of hematoma expansion, a large volume bleed, and poor outcome in hypertensive ICH and may be incorporated into existing prediction models.

Cortical superficial siderosis, hematoma volume, and outcomes after intracerebral hemorrhage: a mediation analysis

“…For decades, cSS has been proven to be a strong risk factor for unfavorable neurologic outcomes and is related to other clinical characteristics that correlate with worse outcomes, such as recurrent ICH and large hematoma (1,(3)(4)(5)(6)(7)(8). However, it is unclear whether the deleterious outcome is determined by cSS or by other potential factors induced by cSS.…”

“…However, it is unclear whether the deleterious outcome is determined by cSS or by other potential factors induced by cSS. We made the hypothesis that part of the effect (indirect effect) of cSS and 90-day mRS was mediated by hematoma volume based on the results of numerous cohort studies that concluded those as follows: (i) cSS is associated with large hematoma volume in patients with ICH; (ii) patients with cSS are more likely to have poor outcomes after ICH, including higher risk of recurrent ICH and poor functional recovery; and (iii) hematoma volume is the most significant factor deciding prognosis of ICH, and large hematoma volume leads to poor outcomes (1,(3)(4)(5)(6)(7)(8). Therefore, a probable relationship chain is that cSS leads to large hematoma volume and then caused poor outcomes.…”

“…Observations from large cohorts revealed that patients with cSS were more likely to have large intracerebral hemorrhage (ICH) volume and hematoma expansion, especially in the lobar area. cSS was also reported to correlate with poor outcomes after ICH (1,(3)(4)(5)(6)(7)(8). However, whether cSS leads to worse outcomes solely by itself or through a specific pathway (especially hematoma volume) and whether cSS-related enlarged hematoma is restricted to the lobar area because of the origin of cSS remain unknown.…”

Application of artificial intelligence‐based magnetic resonance imaging in diagnosis of cerebral small vessel disease

“…Moreover, for the evaluation of WMH, in addition to using different sequences, such as T1‐weighted, T2‐weighted, and T2‐FLAIR, it is necessary to use the Fazekas scale, which is a standard for grading WMH on imaging. 12 , 13 It evaluates paraventricular and deep WMH separately and finally judges the WMH level according to the sum of the scores. Unfortunately, despite its significant impact, accurate diagnosis of CSVD remains a challenge due to variations in imaging protocols, inadequate quantitative metrics, and clinician bias.…”

“…Traditional diagnosis of CSVD is based on a comprehensive evaluation of the typical MRI signs of CVSD to obtain the total load score and provide the corresponding clinical diagnosis decision, such as evaluating the degree of brain atrophy using T1‐weighted MRI images and counting vascular lacunar foci based on T1‐weighted MRI and T2‐fluid‐attenuated inversion recovery (FLAIR) images. Moreover, for the evaluation of WMH, in addition to using different sequences, such as T1‐weighted, T2‐weighted, and T2‐FLAIR, it is necessary to use the Fazekas scale, which is a standard for grading WMH on imaging 12,13 . It evaluates paraventricular and deep WMH separately and finally judges the WMH level according to the sum of the scores.…”