Cerebral Small‐Vessel Disease Markers on Magnetic Resonance Imaging as Predictors of Recurrent Vascular Events and Death in Ischemic Stroke: A Systematic Review and Meta‐Analysis
M. S., Adithya Srinivasan, Shemin Ayesha Shaik Mohideen, Neil Chen Yi Lun MacAlevey, Mark Y. Chan, Aloysius Sheng‐Ting Leow, Xin Zhou, Gregory Y.H. Lip, Benjamin Yong‐Qiang Tan, Leonard L.L. Yeo, Yao Neng Teo, Yao Neng Teo, Yao Hao Teo, Yao Hao Teo, Ching‐Hui Sia
Abstract
BACKGROUND: Cerebral small-vessel disease encompasses a spectrum of magnetic resonance imaging features reflecting microvascular pathology in ischemic stroke. Among these, white matter hyperintensities (WMHs) and cerebral microbleeds (CMBs) are the most widely studied. While both are well established as risk factors for cognitive decline in patients with acute ischemic stroke (AIS), their prognostic value for vascular events and death after AIS remains unclear. This study aims to evaluate WMH and CMB as predictors of recurrent stroke, cardiovascular death, and all-cause death in patients with AIS. METHODS: We systematically searched PubMed and Embase for longitudinal studies from July 1977 to March 2024 reporting adjusted hazard ratios (HRs) or odds ratios for these outcomes after AIS. Pooled estimates were generated using random-effects models, and heterogeneity was explored using meta-regression and prediction intervals. RESULTS: Fifty studies (n=44 140) were included. WMHs were a significant predictor of stroke recurrence (HR,1.72 [95% CI, 1.39-2.13]) and all-cause death (HR, 1.58 [95% CI, 1.11-2.23]). Similarly, CMBs were associated with stroke recurrence (HR, 1.88 [95% CI, 1.52-2.33]), with lobar and mixed types conferring higher risk than deep CMBs, and predicted cardiovascular death (HR, 1.45 [95% CI, 1.2-1.75]). For stroke recurrence, risk estimates increased in parallel with WMH and CMB burden. CONCLUSIONS: This meta-analysis supports WMHs and CMBs as independent predictors of stroke recurrence and death in AIS. Burden and distribution further refine prognostic accuracy and inform poststroke risk assessment.