Cerebral Small Vessel Disease Subtypes and Blood Pressure Control after Intracerebral Hemorrhage
Akashleena Mallick1, Alvin Das2, Sophia Keins1, Jessica Abramson1, Juan Pablo Castello1, Marco Pasi1, Dominique Popescu1, Leidys Gutierrez-Martinez1, Ernst Mayerhofer1, Christina Kourkoulis1, Axana Rodriguez-Torres1, Andrew d. Warren1, Elif Gokcal1, Anand Viswanathan1, Steven M. Greenberg3, Christopher Anderson3, Jonathan Rosand1, Edip Gurol1, Alessandro Biffi1
1Neurology, Massachusetts General Hospital- Harvard Medical School, 2Beth Israel Deaconess Medical Center, 3Neurology, Brigham & Women's Hospital
Objective:
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Background:

Intracerebral hemorrhage (ICH) survivors are at high risk of neurological decline for underlying progressive cerebral small vessel disease (CSVD). Most ICHs are attributable to two common CSVD types: cerebral amyloid angiopathy (CAA) and hypertensive-CSVD (HTN-CSVD). HTN-CSVD includes pure deep or mixed location ICH/microbleeds, the latter more severe. Hypertension control being the most potent intervention delaying CSVD-related ICH progression, we investigated whether more severe forms of HTN-CSVD are related to worse blood pressure (BP) control over time after CSVD-related ICH. 

Design/Methods:

We analyzed data from consecutive non-traumatic ICH in-patients between 2011-2020 in a tertiary care center. MRI-based CSVD markers classified ICH patients as CAA-related and HTN-CSVD-related, deep and mixed locations within HTN-CSVD. Validated MRI-based score quantified CSVD burden. Longitudinal BP following ICH obtained via semi-automated electronic health records review. Linear mixed effects models examined association of BP during follow-up with CSVD etiology and severity.

Results:

796 ICH survivors were followed for a median of 48.8 months (interquartile range [IQR] 41.5 - 60.4). CAA-related (n = 373) displayed lower systolic BP (median 138 mmHg, IQR: 133-142 mmHg) compared to deep hypertensive ICH/microbleeds (n = 222, systolic BP median 141 mmHg, IQR: 136-143 mmHg, p = 0.037 for comparison), and mixed location ICH/microbleeds (n = 201, systolic BP median 142 mmHg, IQR: 135-144 mmHg, p = 0.015 for comparison). In multivariable analysis, mixed location ICH/microbleeds (effect: +3.8 mmHg, Standard Error [SE]: 1.3 mmHg, p = 0.008) and increasing CSVD severity (+1.8 mmHg per score point, SE: 0.8 mmHg, p = 0.032) were independently associated with higher follow-up systolic BP. No associations between CSVD subtype/severity and diastolic BP. 

Conclusions:

CSVD severity and subtype predict subsequent hypertension control. We confirm previous findings that mixed location ICH/microbleeds are related to more severe hypertensive disorder. Our findings support incorporating MRI-derived CSVD markers when tailoring hypertension control strategies for ICH survivors.

10.1212/WNL.0000000000203594