Cortical superficial siderosis predicts early recurrent lobar hemorrhage

Abstract

Objective: To identify predictors of early lobar intracerebral hemorrhage (ICH) recurrence, defined as a new ICH within 6 months of the index event, in patients with cerebral amyloid angiopathy (CAA).

Methods: Participants were consecutive survivors (age ≥55 years) of spontaneous symptomatic probable or possible CAA-related lobar ICH according to the Boston criteria, drawn from an ongoing single-center cohort study. Neuroimaging markers ascertained in CT or MRI included focal (≤3 sulci) or disseminated (>3 sulci) cortical superficial siderosis (cSS), acute convexity subarachnoid hemorrhage (cSAH), cerebral microbleeds, white matter hyperintensities burden and location, and baseline ICH volume. Participants were followed prospectively for recurrent symptomatic ICH. Cox proportional hazards models were used to identify predictors of early recurrent ICH adjusting for potential confounders.

Results: A total of 292 patients were enrolled. Twenty-one patients (7%) had early recurrent ICH. Of these, 24% had disseminated cSS on MRI and 19% had cSAH on CT scan. In univariable analysis, the presence of disseminated cSS, cSAH, and history of previous ICH were predictors of early recurrent ICH (p < 0.05 for all comparisons). After adjusting for age and history of previous ICH, disseminated cSS on MRI and cSAH on CT were independent predictors of early recurrent ICH (hazard ratio [HR] 3.92, 95% confidence interval [CI] 1.38-11.17, p = 0.011, and HR 3.48, 95% CI 1.13-10.73, p = 0.030, respectively).

Conclusions: Disseminated cSS on MRI and cSAH on CT are independent imaging markers of increased risk for early recurrent ICH. These markers may provide additional insights into the mechanisms of ICH recurrence in patients with CAA.

Figure 1. Flow diagram of patient identification, inclusion into the study

CAA = cerebral amyloid angiopathy; ICH = intracerebral hemorrhage.

Figure 2. Disseminated cortical superficial siderosis and early recurrent lobar intracerebral haemorrhage (ICH)

Baseline brain MRI scan and follow-up CT scan of a 79-year-old man who had recurrent symptomatic lobar ICH at 2 months after index ICH. (A) Axial T2*-weighted gradient-recalled echo at baseline demonstrates disseminated cortical superficial siderosis (white arrows) and index ICH in the left posterior frontal parietal area (red arrow). (B) Follow-up axial noncontrast CT scan at 2 months after index ICH demonstrates new subacute lobar intracerebral hemorrhage in the posterior aspect of the left superior frontal gyrus with surrounding edema.

Figure 3. Cortical superficial siderosis (cSS), convexity subarachnoid hemorrhage (cSAH), and early recurrent lobar intracerebral hemorrhage (ICH)

Kaplan-Meier plot estimates the progression of the early recurrent lobar ICH in all patients with cerebral amyloid angiopathy with the presence of (A) focal and disseminated cSS, (B) cSAH detected by CT scan, and (C) cSAH detected by MRI scan.