ABSTRACT NUMBER: ESOC2026A1220 MRI MARKERS OF CEREBRAL SMALL VESSEL DISEASE PRIOR TO FIRST-EVER SPONTANEOUS INTRACEREBRAL HEMORRHAGE

Abstract Background and aims Cerebral small vessel disease (CSVD) is a major contributor to stroke, cognitive decline, and intracerebral hemorrhage (ICH). While MRI markers of CSVD are well described, their role in predicting first-ever ICH remains unclear. Methods We conducted a retrospective case–control study at tertiary stroke center, including patients with first-ever spontaneous ICH between 2012–2024 who had a prior brain MRI, with age and sex-matched controls without ICH. MRI markers of CSVD were rated according to STRIVE-2, including white matter hyperintensities (WMH), lacunes, perivascular spaces (PVS), cerebral microbleeds (CMB), cortical infarcts, superficial siderosis (SS), and acute cortical microinfarcts (CMI). Associations between MRI markers and ICH risk were evaluated using Cox proportional hazards regression (HR) models. Results Altogether, of 2,734 ICH cases, 63 met inclusion criteria and were matched with 63 controls. The mean interval between MRI and ICH was 19 ± 15 months. In univariable analyses, WMH (HR=2.10, 95% CI 1.27–3.45, p<0.01), lacunar infarcts (HR=2.11, 95% CI 1.26–3.52, p<0.01), severe PVS (HR=3.05, 95% CI 1.71–5.43, p<0.01), acute CMI (HR=4.25, 95% CI 1.67–10.81, p<0.01), and CMB (HR=4.12, 95% CI 2.38–7.13, p<0.01) were associated with ICH risk. Patients with the combination of CMB and SS had the highest ICH risk (HR=4.62, 95% CI 2.65–8.05, p<0.01). Conclusions MRI-defined CSVD markers are strong predictors for first-ever ICH. Brain imaging may help identify high-risk patients and guide preventive strategies. Prospective validation in larger cohorts is warranted. Conflict of interest nothing to disclose"