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Randomized Controlled Trial
. 2021 Jan;52(2):595-602.
doi: 10.1161/STROKEAHA.120.031628. Epub 2021 Jan 20.

Diffusion-Weighted Imaging Lesions After Intracerebral Hemorrhage and Risk of Stroke: A MISTIE III and ATACH-2 Analysis

Santosh B Murthy  1 , Cenai Zhang  1 , Ajay Gupta  2 , Sung-Min Cho  3 , Lucia Rivera-Lara  3 , Radhika Avadhani  4 , Joshua Gruber  4 , Costantino Iadecola  1 , Guido J Falcone  5 , Kevin N Sheth  5 , Adnan I Qureshi  6 , Joshua N Goldstein  7 , Daniel F Hanley  4 , Hooman Kamel  1 , Wendy C Ziai  3
Affiliations
Randomized Controlled Trial

Diffusion-Weighted Imaging Lesions After Intracerebral Hemorrhage and Risk of Stroke: A MISTIE III and ATACH-2 Analysis

Santosh B Murthy et al. Stroke. 2021 Jan.

Abstract

Background and purpose: Punctate ischemic lesions noted on diffusion-weighted imaging (DWI) are associated with poor functional outcomes after intracerebral hemorrhage (ICH). Whether these lesions increase long-term risk of stroke is poorly understood.

Methods: We pooled individual patient data from the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) and the MISTIE III trial (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase 3). We included subjects with a magnetic resonance imaging scan. The exposure was a DWI lesion. The primary outcome was any stroke, defined as a composite of ischemic stroke or recurrent ICH, whereas secondary outcomes were incident ischemic stroke and recurrent ICH. Using multivariate Cox regression analysis, we evaluated the risk of stroke.

Results: Of 505 patients with ICH with magnetic resonance imaging, 466 were included. DWI lesions were noted in 214 (45.9%) subjects, and 34 incident strokes (20 ischemic stroke and 14 recurrent ICH) were observed during a median follow-up of 324 days (interquartile range, 91-374). Presence of a DWI lesion was associated with a 6.9% (95% CI, 2.2-11.6) absolute increase in risk of all stroke (hazard ratio, 2.6 [95% CI, 1.2-5.7]). Covariate adjustment with Cox regression models also demonstrated this increased risk. In the secondary analyses, there was an increased risk of ischemic stroke (hazard ratio, 3.5 [95% CI, 1.1-11.0]) but not recurrent ICH (hazard ratio, 1.7 [95% CI, 0.6-5.1]).

Conclusions: In a heterogeneous cohort of patients with ICH, presence of a DWI lesion was associated with a 2.5-fold heightened risk of stroke among ICH survivors. This elevated risk persisted for ischemic stroke but not for recurrent ICH.

Keywords: cerebral hemorrhage; hematoma; hypertension; magnetic resonance imaging; risk.

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Figures

Figure 1:
Figure 1:
Magnetic Resonance Imaging of an Acute Intracerebral Hemorrhage. Susceptibility weighted angiography (SWAN) showing the hematoma (Panel A), and diffusion-weighted imaging (DWI) sequences showing hyperintense lesions (Panels B and C).
Figure 2:
Figure 2:
Flowchart Showing Patient Selection Abbreviations: DWI, diffusion-weighted imaging; ICH, intracerebral hemorrhage; MRI, magnetic resonance imaging.
Figure 3:
Figure 3:
Kaplan-Meier Survival Curve Showing Risk of an Ischemic Stroke Among ICH Patients with and without DWI Lesions. Abbreviations: DWI, diffusion-weighted imaging; ICH, intracerebral hemorrhage.
Figure 4:
Figure 4:
Kaplan-Meier Survival Curves Showing Risk of Stroke Subtypes Among ICH Patients with and without DWI Lesions; Risk of Ischemic Stroke (Left Panel) and Risk of Recurrent ICH (Right Panel). Abbreviations: DWI, diffusion-weighted imaging; ICH, intracerebral hemorrhage.
See this image and copyright information in PMC

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