Goeldlin Martina B, Küttner Rosa, Drop Boudewijn, Siepen Bernhard Matthias, Rauch Janis Patricia, Auer Elias, Hakim Arsany, Radojewski Piotr, Mujanovic Adnan, Sveikata Lukas, Mueller Achim, Zietz Annaelle, Polymeris Alexandros A, Engelter Stefan T, Katan Mira, Carrera Emmanuel, De Marchis Gian Marco, Dittrich Tolga Daniel, Cereda Carlo W, Bianco Giovanni, Wegener Susanne, Strambo Davide, Bolognese Manuel, Kaesmacher Johannes, Meinel Thomas R, Z'Graggen Werner J, Fischer Urs, Arnold Marcel, Volbers Bastian, Kristoffersen Espen Saxhaug, Lemmens Robin, Seiffge David Julian
Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland.
University Institute of Diagnostic and Interventional Neuroradiology, Inselspital Bern University Hospital and University of Bern, Switzerland.
Neurology. 2025 Jul 22;105(2):e213837. doi: 10.1212/WNL.0000000000213837. Epub 2025 Jun 19.
Diffusion-weighted imaging (DWI) lesions in patients with intracerebral hemorrhage (ICH) are associated with poor outcomes. Knowledge about the underlying pathophysiology is scarce, and it is hypothesized that they are related to either the ICH itself, adverse effects of treatment, or the activity of the underlying small vessel disease (SVD) causing the ICH. We investigated their association with time point of MRI acquisition and underlying SVD type and burden.
In this Swiss multicenter ICH cohort, we enrolled patients who underwent MRI within 15 days after SVD-associated ICH. The primary outcome was presence of DWI lesions. Time point of MRI was investigated as a continuous (days) and dichotomized (hyperacute = MRI on admission vs subacute = MRI during follow-up) variable. We measured cerebral amyloid angiopathy (CAA) and SVD severity using MRI burden scores and defined the type of SVD using CADMUS classification and Boston 2.0 criteria. At 3 months, we assessed functional outcome using the modified Rankin Scale score, recurrent ICH, and ischemic stroke.
We included 644 patients (median age 73 years, interquartile range [IQR] 64-79, median SVD burden 1 IQR 1-2; median CAA burden 2 IQR 1-3; 208 patients/32.3% with Boston 2.0 CAA, 431 patients/66.9% with mixed CAA-DPA phenotype according to CADMUS). Among enrolled patients, 16.0% underwent hyperacute MRI and 84.0% underwent subacute MRI (median on day 2 IQR 1-5), and 166 patients (25.8%) had DWI lesions (18.4% with hyperacute MRI vs 27.2% with subacute MRI). We observed no association of presence of DWI lesions with hyperacute MRI (adjusted odds ratio [aOR] 0.61, 95% CI 0.36-1.00, = 0.073) but with time to MRI in days (aOR 1.07, 95% CI 1.00-1.13, = 0.007). Higher SVD (aOR 1.33, 95% CI 1.12-1.59, = 0.001) and CAA (aOR 1.29, 95% CI 1.15-1.44, < 0.001) burdens were associated with presence of DWI lesions. There was no association between type of SVD (CADMUS) or CAA (Boston criteria) and DWI lesions. There was no association between DWI lesions and functional outcome, recurrent ICH or ischemic stroke at 3 months.
DWI lesions in patients with ICH are already common at baseline. Their prevalence is higher with a longer time since symptom onset and with higher SVD burden. Overall, these findings suggest a relation with the underlying condition resulting in ICH. The significant number of DWI lesions visible on admission MRI might diminish their use as surrogate outcome in future trials in ICH.
脑出血（ICH）患者的弥散加权成像（DWI）病变与不良预后相关。关于其潜在病理生理学的知识匮乏，据推测这些病变与ICH本身、治疗的不良反应或导致ICH的潜在小血管疾病（SVD）的活动有关。我们研究了它们与MRI采集时间点以及潜在SVD类型和负担的关联。
在这个瑞士多中心ICH队列中，我们纳入了在SVD相关ICH后15天内接受MRI检查的患者。主要结局是DWI病变的存在情况。MRI的时间点作为连续变量（天数）和二分变量（超急性期 = 入院时MRI与亚急性期 = 随访期间MRI）进行研究。我们使用MRI负担评分测量脑淀粉样血管病（CAA）和SVD严重程度，并使用CADMUS分类和波士顿2.0标准定义SVD类型。在3个月时，我们使用改良Rankin量表评分、复发性ICH和缺血性卒中评估功能结局。
我们纳入了644例患者（中位年龄73岁，四分位间距[IQR]64 - 79，中位SVD负担1 IQR 1 - 2；中位CAA负担2 IQR 1 - 3；根据CADMUS，208例患者/32.3%为波士顿2.0 CAA，431例患者/66.9%为CAA - DPA混合表型）。在纳入的患者中，16.0%接受了超急性期MRI检查，84.0%接受了亚急性期MRI检查（中位时间为第2天IQR 1 - 5），166例患者（25.8%）有DWI病变（超急性期MRI检查者中为18.4%，亚急性期MRI检查者中为27.2%）。我们观察到DWI病变的存在与超急性期MRI检查无关联（调整优势比[aOR]0.61，95%置信区间0.36 - 1.00，P = 0.073），但与MRI检查时间（天数）有关（aOR 1.07，95%置信区间1.00 - 1.13，P = 0.007）。较高的SVD（aOR 1.33，95%置信区间1.12 - 1.59，P = 0.001）和CAA（aOR 1.29，95%置信区间1.15 - 1.44，P < 0.001）负担与DWI病变的存在相关。SVD类型（CADMUS）或CAA（波士顿标准）与DWI病变之间无关联。DWI病变与3个月时的功能结局、复发性ICH或缺血性卒中之间无关联。
ICH患者的DWI病变在基线时就已很常见。症状出现后时间越长且SVD负担越高，其患病率越高。总体而言，这些发现提示与导致ICH的潜在疾病有关。入院时MRI上可见的大量DWI病变可能会降低其在未来ICH试验中作为替代结局的用途。
