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Underlying microangiopathy and functional outcome of simultaneous multiple intracerebral hemorrhage
Jiawen Li1, Dan Shen1, Yanli Zhou1
1Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
Insights
Simultaneous multiple intracerebral hemorrhages (SMICH) are often linked to hypertensive small vessel disease (SVD) and carry a high risk of poor outcomes. Identifying SVD types is crucial for understanding SMICH prognosis.
Area of Science:
- Neurology
- Neuroimaging
- Cerebrovascular Disease
Background:
- Cerebral small vessel disease (SVD) is a significant contributor to various neurological conditions.
- Simultaneous multiple intracerebral hemorrhages (SMICH) represent a severe manifestation of SVD, yet the predominant SVD types and their impact on outcomes remain incompletely understood.
- Understanding the underlying SVD in SMICH is critical for risk stratification and management.
Purpose of the Study:
- To determine the predominant type of cerebral small vessel disease (SVD) in patients presenting with simultaneous multiple intracerebral hemorrhages (SMICH).
- To investigate the clinical characteristics and outcomes associated with SMICH compared to single intracerebral hemorrhage (ICH).
- To identify risk factors and potential etiologies contributing to SMICH.
Main Methods:
- Retrospective review of a single-center prospective cohort of intracerebral hemorrhage (ICH) patients.
- Classification of presumed etiology using the SMASH-U criteria.
- Comparison of demographics, clinical variables, laboratory data, and neuroimaging findings between SMICH and single ICH cohorts; functional outcomes assessed using the modified Rankin scale at 90 days.
Main Results:
- Of 598 ICH patients, 37 (6.2%) had SMICH. Risk factors included deep cerebral microbleeds (CMBs), white matter hyperintensities, prior ICH, and low serum magnesium.
- Hypertension was the most common cause (40.5%), followed by undetermined etiology (45.9%). Undetermined SMICH cases showed higher deep CMB burden compared to hypertension-ICH and cerebral amyloid angiopathy-ICH.
- SMICH was independently associated with poor functional outcomes at 90 days (OR 2.23).
Conclusions:
- Hypertensive SVD is the principal angiopathy in most primary SMICH cases.
- Patients with SMICH face a significantly elevated risk of poor neurological outcomes.
- Further research into undetermined etiologies of SMICH is warranted, focusing on microangiopathic changes.
Objective:
To identify the predominant type of cerebral small vessel disease (SVD) and outcomes in patients with simultaneous multiple intracerebral hemorrhages (SMICH).
Methods:
Consecutive patients with intracerebral hemorrhage (ICH) from a single-center prospective cohort were retrospectively reviewed. Presumed etiology was classified according to the SMASH-U criteria. Demographics, clinical and laboratory variables, and neuroimaging data were compared between patients with primary SMICH and those with single ICH. Functional outcomes were assessed using the modified Rankin scale 90 days after ICH.
Results:
Of the 598 enrolled patients, 37 (6.2%) met the criteria for SMICH. Risk factors for SMICH included a high burden of deep cerebral microbleeds (CMBs) (odds ratio [OR] 1.06, 95% confidence interval [CI], 1.00-1.12; p = 0.040), white matter hyperintensity scores (OR 1.27, 95% CI 1.04-1.57; p = 0.021), history of ICH (OR 3.38, 95% CI 1.31-8.05; p = 0.008), and low serum magnesium levels (OR 0.01, 95% CI 0.00-0.25; p = 0.007). Based on the SMASH-U classification, 15(40.5%) SMICH were classified as hypertension, whereas 17 (45.9%) as undetermined-etiology. To further explore the potential microangiopathy underlying undetermined-SMICH, these patients with undetermined-etiology were compared to those with cerebral amyloid angiopathy-ICH, and were associated with a higher burden of deep CMBs but less severe centrum semiovale enlarged perivascular spaces. Likewise, compared with hypertension-ICH patients, those with undetermined SMICH were consistently associated with a higher deep CMB counts. Moreover, multivariate analysis revealed that SMICH was independently associated with poor outcomes (OR 2.23, 95%CI 1.03-4.76; p = 0.038).
Conclusion:
Our results suggest that most patients with primary SMICH harbor hypertensive-SVD as principal angiopathy. Patients with SMICH are at a high risk of poor outcomes. (ClinicalTrials.gov Identifier: NCT04803292).
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