The recent update to the Boston criteria for CAA adds two neuroimaging markers to increase the sensitivity of CAA detection: multispot white matter hyperintensity (WMH) pattern and severe centrum semiovale enlarged perivascular spaces (CSO EPVS). While these non-hemorrhagic markers, together with well-established hemorrhagic markers such as lobar cerebral microbleeds (CMBs) and cortical superficial siderosis (cSS), increases the likelihood of underlying CAA in patients with ICH, it is unclear whether they impact clinical outcomes.

To diagnose CAA, brain MRIs from a prospective database of consecutive non-traumatic ICH patients admitted to a tertiary care center were reviewed for the presence of CMBs, cSS, multispot WMH pattern, and CSO EPVS. Clinical and neuroimaging predictors of an unfavorable discharge outcome (modified Rankin score ≥ 4) were assessed in univariable and multivariable models.

Between 2003 and 2019, 645 (36%) of 1,791 ICH patients were diagnosed with CAA (mean age 74±11 years, 49% female) based on available MRIs (performed in 72%). Lobar CMBs occurred in 326 (51%) patients, cSS occurred in 197 (31%), multispot WMH pattern occurred in 123 (19%), and severe CSO EPVS occurred in 156 (24%). In univariable analyses, age, hypertension, diabetes, ischemic stroke history, dementia, admission Glasgow Coma Scale (GCS) scores, intubation, external ventricular drain placement, hematoma evacuation, intraventricular extension, and cSS were associated with an unfavorable discharge outcome (all p < 0.05). When these variables were entered into a multivariable model subjected to backward elimination, age, hypertension, dementia, GCS score, intubation, intraventricular extension, and cSS (aOR 1.75, 95% CI 1.07–2.88) remained significantly associated with an unfavorable outcome.

Although hemorrhagic and non-hemorrhagic neuroimaging markers are common in CAA patients with ICH, only cSS is significantly associated with unfavorable clinical outcomes.