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. 2023 Dec;8(4):989-1000.
doi: 10.1177/23969873231193237. Epub 2023 Aug 26.

Small vessel disease burden and risk of recurrent cerebrovascular events in patients with lacunar stroke and intracerebral haemorrhage attributable to deep perforator arteriolopathy

Martina B Goeldlin  1   2 , Jan Vynckier  1   3 , Madlaine Mueller  1   2 , Boudewijn Drop  1 , Basel Maamari  1 , Noah Vonlanthen  1 , Bernhard M Siepen  1   2 , Arsany Hakim  4 , Johannes Kaesmacher  4 , Christopher Marvin Jesse  5 , Mandy D Mueller  5 , Thomas R Meinel  1 , Morin Beyeler  1   2 , Leander Clénin  1 , Jan Gralla  4 , Werner Z'Graggen  1   5 , David Bervini  5 , Marcel Arnold  1 , Urs Fischer  1   6 , David J Seiffge  1
Affiliations

Small vessel disease burden and risk of recurrent cerebrovascular events in patients with lacunar stroke and intracerebral haemorrhage attributable to deep perforator arteriolopathy

Martina B Goeldlin et al. Eur Stroke J. 2023 Dec.

Abstract

Introduction: Deep perforator arteriolopathy (DPA) causes intracerebral haemorrhage (ICH) and lacunar strokes (LS). We compare patient characteristics, MRI findings and clinical outcomes among patients with deep ICH and LS.

Patients and methods: We included patients with MRI-confirmed LS or ICH in the basal ganglia, thalamus, internal capsule or brainstem from the Bernese Stroke Registry. We assessed MRI small vessel disease (SVD) markers, SVD burden score, modified Rankin Scale (mRS) and ischaemic stroke or ICH at 3 months.

Results: We included 716 patients, 117 patients (16.3%) with deep ICH (mean age (SD) 65.1 (±15.2) years, 37.1% female) and 599 patients (83.7%) with LS (mean age (SD) 69.7 (±13.6) years, 39.9% female). Compared to LS, deep ICH was associated with a higher SVD burden score (median (IQR) 2 (1-2) vs 1 (0-2)), aORshift 3.19, 95%CI 2.15-4.75). Deep ICH patients had more often cerebral microbleeds (deep ICH: 71.6% vs LS: 29.2%, p < 0.001, median count (IQR) 4(2-12) vs 2(1-6)) and a higher prevalence of lacunes (deep ICH: 60.5% vs LS: 27.4% p < 0.001). At 3 months, deep ICH was associated with higher mRS (aORshift 2.16, 95%CI 1.21-3.87). Occurrence of ischaemic stroke was numerically but not significantly higher in deep ICH (4.3% vs 2.9%; p = 0.51). One patient (1.1%) with ICH but none with LS suffered ICH recurrence.

Discussion/conclusion: DPA manifesting as ICH is associated with more severe MRI SVD burden and worse outcome compared to LS. The short-term risks of subsequent ischaemic stroke and recurrent ICH are similar in ICH and LS patients. This implies potential consequences for future secondary prevention strategies.

Keywords: Lacunar stroke; MRI; clinical outcomes; deep perforator arteriopathy; hypertension; intracerebral haemorrhage; neuroimaging.

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Conflict of interest statement

Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Goeldlin: Grants from Swiss Academy of Medical Sciences/Bangerter-Rhyner-Foundation, Mittelbauvereinigung der Universität Bern (outside the submitted work), Swiss Stroke Society (Förderpreis), European Stroke Organisation (department to department visit grant), Insel Gruppe, and Pfizer congress grant (outside the submitted work). Dr. Siepen: Funding by the Bangerter-Rhyner-Foundation (outside the submitted work). Dr. Fischer: research support from Swiss National Science Foundation, Swiss Heart Foundation, Medtronic (BEYOND SWIFT, SWIFT DIRECT), Stryker, Rapid medical, Penumbra, Phenox (DISTAL), consultancies for Medtronic, Stryker, and CSL Behring (fees paid to institution), participation in an advisory board for Alexion/Portola and Boehringer Ingelheim (fees paid to institution).Dr. Seiffge: Advisory board for Bayer and Portola/Alexion, Research grant from the Bangerter-Rhyner Foundation. All other authors do not report conflicts of interest.

Figures

Graphical abstract
Graphical abstract
Figure 1.
Figure 1.
Study flowchart. Flowchart of patients with intracerebral haemorrhage (ICH) and ischaemic stroke in the Bernese ICH and stroke registries.
Figure 2.
Figure 2.
Small vessel disease burden score. ICH: intracerebral haemorrhage; mRS: modified Rankin scale. Comparison of small vessel disease burden score in patients with lacunar stroke versus deep intracerebral haemorrhage (ICH). Small vessel disease burden was significantly higher in patients with deep ICH (p < 0.001).
Figure 3.
Figure 3.
Outcomes in patients with deep ICH versus lacunar stroke: (a) Comparison of pre-event and 3 month modified Rankin Scale (mRS) in patients with lacunar stroke (n = 476) versus deep ICH (n = 91). Pre-event and 3 month mRS were significantly higher in patients with deep ICH (p < 0.001 for both timepoints) and (b) Event rates in patients with lacunar stroke versus deep intracerebral haemorrhage (ICH) at 3 month follow-up. Patients with deep ICH had numerically higher rates of cerebrovascular events compared to patients with LS but this difference was not statistically significant (p for ischaemic stroke at follow-up 0.51, p for ICH at follow-up 0.18). ICH: intracerebral haemorrhage; AIS: acute ischaemic stroke; SVD: small vessel disease.
See this image and copyright information in PMC

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