New ischemic lesions coexisting with acute intracerebral hemorrhage

Objectives: Acute cerebral infarction may coexist with hypertensive intracerebral hemorrhage (ICH) because lacunae and hypertensive ICH share common risk factors and small-vessel pathology. We sought to determine the frequency and predictors of new ischemic lesions (NIL) on diffusion-weighted imaging (DWI), in patients with acute hypertensive ICH, and to investigate whether NIL predicts subsequent clinical cerebrovascular events.

Methods: This prospective study enrolled 97 patients with acute hypertensive ICH diagnosed within 3 days after onset. DWI and gradient echo T2*-weighted imaging were performed 5 days after onset. NIL was defined as hyperintense DWI lesions accompanying low intensity on apparent diffusion coefficient maps. Patients were regularly followed up for subsequent clinical cerebrovascular events or vascular deaths.

Results: Forty-nine asymptomatic NILs were observed in 26 (26.8%) patients, with 37 of the 49 NILs (75.5%) located in subcortical white matter or brainstem. Multiple logistic regression analysis showed that baseline microbleeds >2 and moderate to severe white matter leukoaraiosis were independently associated with NIL. During a median follow-up of 42 months (interquartile range, 38–47 months), 9 patients experienced clinical cerebrovascular events or vascular deaths. Cox proportional hazards models showed that NILs were independently associated with the composite of clinical cerebrovascular events or vascular death and marginally associated with clinical ischemic stroke.

Conclusions: NILs frequently occur during the acute phase of ICH and are mainly associated with small-vessel pathogenesis. NILs occurring together with ICH may be a useful marker to identify patients at high risk of future clinical cerebrovascular events or vascular death.