Restricted accessResearch articleFirst published online 2025-8
Predicting poor 90-day prognosis in acute spontaneous intracerebral hemorrhage patients using initial MRI signs of cerebral small vessel disease (CSVD): a retrospective cohort study
Various factors impact the prognosis of the patients with intracerebral hemorrhage (ICH).
Purpose
To evaluate the initial magnetic resonance imaging (MRI) indicators of cerebral small vessel disease (CSVD) and evaluate the relationship between the MRI indicators and ICH prognosis.
Material and Methods
Clinical and imaging data were collected from individuals diagnosed with acute ICH who had undergone MRI within 48 h of symptom onset between October 2021 and March 2022. The 90-day modified Rankin Scale (mRS) scores were analyzed, focusing on identifying those patients with a mRS score ≥3 points, which was consistent with a poor prognosis.
Results
A total of 220 ICH patients were evaluated, with 81 (36.8%) having a poor prognosis at 90 days. The study identified encephalatrophy (P = 0.014, odds ratio [OR] = 2.431, 95% confidence interval [CI] = 1.242–3.768), grade 2 periventricular Fazekas scale (P = 0.021, OR = 2.389, 95% CI = 1.174–2.869), centrum semiovale perivascular space (P = 0.035, OR = 2.296, 95% CI = 1.110–3.798), age (P = 0.002, OR = 1.046, 95% CI = 1.017–1.077), female sex (P = 0.015, OR = 0.463, 95% CI = 0.250–0.859), and admission National Institutes of Health Stroke Scale score (P = 0.003, OR = 1.052, 95% CI = 1.022–1.084) as independent risk factors for poor prognosis of an ICH. The incorporation of MRI findings significantly enhanced the predictive accuracy of the poor prognosis model in comparison to a model lacking MRI findings (AUC = 0.833 vs. 0.815, net reclassification index = 0.186; P = 0.021, integrated discrimination improvement = 0.158; P = 0.016).
Conclusion
Identification of initial MRI findings of CSVD, such as white matter hyperintensity, perivascular spaces, cerebral microbleeds, lacunar infarcts, brain atrophy, and leukodystrophy, has the potential to enhance prognostication of patients with ICHs.
Apostolaki-HanssonTUllbergTPihlsgårdM, et al.Prognosis of intracerebral hemorrhage related to antithrombotic use: an observational study from the Swedish Stroke Register (Riksstroke). Stroke2021;52:966–974.
2.
WitschJSiegerinkBNolteCH, et al.Prognostication after intracerebral hemorrhage: a review. Neurol Res Pract2021;3:1–14.
3.
GopinathM. Functional outcome prediction using FUNC score in primary intracerebral hemorrhage patients admitted to medical wards in a tertiary care hospital: Academic department, Madras Medical College, Chennai, 2022.
4.
Chojdak-ŁukasiewiczJDziadkowiakEZimnyA, et al.Cerebral small vessel disease: a review. Adv Clin Exp Med2021;30:349–356.
5.
WangSZouX-LWuL-X, et al.Epidemiology of intracerebral hemorrhage: a systematic review and meta-analysis. Front Neurol2022;13:915813.
6.
Rodriguez LaraFToroARPinheiroA, et al.Relation of MRI-visible perivascular spaces and other MRI markers of cerebral small vessel disease. Brain Sci2023;13:1323.
7.
TangGCaoZLuoY, et al.Prognosis associated with asymptomatic intracranial hemorrhage after acute ischemic stroke: a systematic review and meta-analysis. J Neurol2022;269:3470–3481.
8.
Hemphill IIIJCBonovichDCBesmertisL, et al.The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke2001;32:891–897.
9.
Simon-PimmelJFoucherYLégerM, et al.Methodological quality of multivariate prognostic models for intracranial haemorrhages in intensive care units: a systematic review. BMJ Open2021;11:e047279.
10.
CarhuapomaLMurthySShahVA. Outcome trajectories after intracerebral hemorrhage. Semin Neurol2024;44:298–307.
11.
BaeSBKimS. Imaging features of hyperacute intracerebral hemorrhage on multiple MRI sequences within 1 minute from onset during MRI examination: a case report. Medicine (Baltimore)2023;102:e33350.
12.
MartiniSRFlahertyMLBrownWM, et al.Risk factors for intracerebral hemorrhage differ according to hemorrhage location. Neurology2012;79:2275–2282.
13.
RoblesLAVoloviciV. Hypertensive primary intraventricular hemorrhage: a systematic review. Neurosurg Rev2022;45:2013–2026.
14.
MoranCPhanTGSrikanthVK. Cerebral small vessel disease: a review of clinical, radiological, and histopathological phenotypes. Int J Stroke2012;7:36–46.
15.
AngermannMJablawiFAngermannM, et al.Clinical outcome and prognostic factors of patients with perimesencephalic and nonperimesencephalic subarachnoid hemorrhage. World Neurosurg2022;165:e512–e519.
16.
BarberPAKleinigTJ. INTERACT2: A reason for optimism with spontaneous intracerebral hemorrhage?Int J Stroke2014;9:59–60.
17.
WardlawJMSmithEEBiesselsGJ, et al.Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration. Lancet Neurol2013;12:822–838.
18.
VanderverAPrustMTondutiD, et al.Case definition and classification of leukodystrophies and leukoencephalopathies. Mol Genet Metab2015;114:494–500.
19.
LinnJHalpinADemaerelP, et al.Prevalence of superficial siderosis in patients with cerebral amyloid angiopathy. Neurology2010;74:1346–1350.
Valdés HernándezMMorrisZDickieDA, et al.Close correlation between quantitative and qualitative assessments of white matter lesions. Neuroepidemiology2012;40:13–22.
22.
LeonteALaurent-ChabalierSWacongneA, et al.Brain hemorrhage on 24h-CT and functional outcome in stroke patients with cerebral amyloid angiopathy features on pre-thrombolysis MRI treated with intravenous thrombolysis: a case series. J Stroke Cerebrovasc Dis2023;32:106907.
23.
FazekasFChawlukJBAlaviA, et al.MR Signal abnormalities at 1.5T in Alzheimer's dementia and normal aging. AJR Am J Roentgenol1987;149:351–356.
24.
CharidimouABoulouisGHaleyK, et al.White matter hyperintensity patterns in cerebral amyloid angiopathy and hypertensive arteriopathy. Neurology2016;86:505–511.
25.
KazuiSNaritomiHYamamotoH, et al.Enlargement of spontaneous intracerebral hemorrhage: incidence and time course. Stroke1996;27:1783–1787.
26.
AlbaACAgoritsasTWalshM, et al.Discrimination and calibration of clinical prediction models: users’ guides to the medical literature. JAMA2017;318:1377–1384.
27.
GaravelliFGhelfiAMKilsteinJG. Usefulness of NIHSS score as a predictor of non-neurological in-hospital complications in stroke. Med Clin (Barc)2021;157:434–437.
28.
RoquerJRodríguez CampelloAGomisM, et al.Previous antiplatelet therapy is an independent predictor of 30–day mortality after spontaneous supratentorial intracerebral hemorrhage. J Neurol2005;252:412–416.
29.
GantiLShameemMHouckJ, et al.Gender disparity in stoke: women have higher ICH scores than men at initial ED presentation for intracerebral hemorrhage. J Natl Med Assoc2023;115:186–190.
30.
Gama LoboGFragataI. Long-term global and focal cerebral atrophy in perimesencephalic subarachnoid hemorrhage—a case–control study. Neuroradiology2022;64:669–674.
31.
O’CarrollCBBrownBLFreemanWD. Intracerebral hemorrhage: a common yet disproportionately deadly stroke subtype. Mayo Clin Proc2021;96:1639–1654.
32.
Uniken VenemaSMMariniSLenaUK, et al.Impact of cerebral small vessel disease on functional recovery after intracerebral hemorrhage. Stroke2019;50:2722–2728.
33.
ChoEJKimSMParkY-S, et al.MRI assessment of cerebral small vessel disease in patients with spontaneous intracerebral hemorrhage. Yonsei Med J2019;60:774–781.
34.
KalisvaartACBahrNAColbourneF. Relationship between edema and intracranial pressure following intracerebral hemorrhage in rat. Front Stroke2023;2:1155937.
35.
BestJGAmblerGWilsonD, et al.Clinical associations and prognostic value of MRI-visible perivascular spaces in patients with ischemic stroke or TIA: a pooled analysis. Neurology2024;102:e207795.
36.
ZhangD-DCaoYMuJ-Y, et al.Inflammatory biomarkers and cerebral small vessel disease: a community-based cohort study. Stroke Vasc Neurol2022;7:302–309.
37.
JurcauASimionA. Neuroinflammation in cerebral ischemia and ischemia/reperfusion injuries: from pathophysiology to therapeutic strategies. Int J Mol Sci2022;23:14.
38.
WangXFengHWangY, et al.Enlarged perivascular spaces and cerebral small vessel disease in spontaneous intracerebral hemorrhage patients. Front Neurol2019;10:881.
39.
BahMGDowlatiEFleignerM, et al.MR imaging-based biomarker development in hemorrhagic stroke patients including brain iron quantification, diffusion tensor imaging, and phenomenon of ultra-early erythrolysis. Neuroimaging Clin N Am2024;34:215–224.
40.
KawaseTBishnoiITanakaR, et al.Study of incidence and factors: risk and preventive, of chronic subdural hematoma/hygroma in clipped patients of unruptured intracranial aneurysms–an institutional experience. Asian J Neurosurg2018;13:707–713.
41.
MiahIPHollDCBlaauwJ, et al.Dexamethasone versus surgery for chronic subdural hematoma. N Engl J Med2023;388:2230–2240.
42.
MiahIPHollDCPeulWC, et al.Dexamethasone therapy versus surgery for chronic subdural haematoma (DECSA trial): study protocol for a randomised controlled trial. Trials2018;19:575.
43.
WangQMengLWangZ. Combined cerebral microbleeds with lacunar infarctions in familial cerebral cavernous malformations. JAMA Neurol2019;76:1117–1118.
44.
ZhengTMouXZhangJ, et al.Clinical effect and changes of ET-1, FMD and NO levels in the treatment of acute cerebral infarction with acanthopanax injection. Am J Transl Res2021;13:3600.
45.
LvGWangG-qXiaZ-x, et al.Influences of blood lipids on the occurrence and prognosis of hemorrhagic transformation after acute cerebral infarction: a case-control study of 732 patients. Mil Med Res2019;6:2.
46.
YuZZhengJAliH, et al.Significance of satellite sign and spot sign in predicting hematoma expansion in spontaneous intracerebral hemorrhage. Clin Neurol Neurosurg2017;162:67–71.
47.
ShoamaneshAMorottiARomeroJM, et al.Cerebral microbleeds and the effect of intensive blood pressure reduction on hematoma expansion and functional outcomes: a secondary analysis of the ATACH-2 randomized clinical trial. JAMA Neurol2018;75:850–859.
48.
ValyrakiNGoujonAMateosM, et al.MRI spot sign in acute intracerebral hemorrhage: an independent biomarker of hematoma expansion and poor functional outcome. J Neurol2023;270:1531–1542.
49.
De ReuckJ. Lobar intracerebral haematomas: a review. Case Rep Rev Open Access2021;2:122.
50.
Graff-RadfordJLesnickTRabinsteinAA, et al.Cerebral microbleed incidence, relationship to amyloid burden: the Mayo Clinic Study of Aging. Neurology2020;94:e190–e199.
