Prospective study of primary aldosteronism in acute ischemic stroke: association with small vessel disease

Primary aldosteronism (PA), characterized by autonomous overproduction of aldosterone, may increase the risk of acute ischemic stroke (AIS) through mechanisms involving oxidative stress and vascular endothelial damage, potentially contributing to cerebral small vessel disease (SVD). This study aimed to determine the prevalence of PA in AIS patients and explore the association between SVD markers and PA. Consecutive AIS patients hospitalized between October 2020 and December 2022 were prospectively enrolled. Positive PA screening was defined as an aldosterone-to-renin ratio >200. Final PA diagnosis was judged by endocrinologists based on positive results from captopril challenge, saline infusion, and furosemide-upright tests performed after a sufficient interval from onset. SVD burden was evaluated using total SVD score, which assesses white matter hyperintensities (periventricular and deep/subcortical), cerebral microbleeds (CMBs; deep, lobar, and infratentorial), perivascular spaces, and old lacunes. Of 130 enrolled patients, 120 were included (78% male; median age, 62 years). PA screening was positive in 28% (33/120), of whom 24% (8/33) were confirmed as definite PA. Total SVD score was significantly associated with positive PA screening (PR 1.261, 95%CI 1.021-1.556, p = 0.031) and definite PA diagnosis (PR 1.946, 95%CI 1.229-3.082, p = 0.005). Severe periventricular hyperintensity (PVH) and deep/lobar CMBs were independently associated with positive PA screening and definite diagnosis (p < 0.05). In AIS patients, PA screening positivity was 28%, and definite PA diagnosis was confirmed in 24% of screening-positive patients. SVD burden, especially PVH and deep/lobar CMBs, is closely associated with PA.