High burden and unique pattern of cerebral small vessel disease in antiphospholipid syndrome: MRI subtypes and risk profile in a large cohort

Objective To characterize the burden and MRI subtypes of cerebral small vessel disease (cSVD) in antiphospholipid syndrome (APS) and to identify clinical factors associated with cSVD. Methods We retrospectively analyzed 132 patients with APS and age- and sex-matched healthy controls. MRI markers for cSVD, including lacunes, enlarged perivascular spaces (EPVS), microbleeds, and white matter hyperintensities (WMH), were rated using validated scales. Total cSVD scores (0–4) were calculated. Logistic regression analyses adjusted for age, sex, and disease duration were used to identify risk factors. Results More than half of patients with APS (51.5%) exhibited cSVD, whereas only 24.2% had a history of stroke. Lacunes were the predominant subtype (46.2%), followed by WMH (16.7%), EPVS (14.4%), and microbleeds (12.1%). Subclinical cSVD was present in 34.8% of patients with APS without neurological symptoms. Hypertension (OR 3.69, 95%CI 1.17-11.65, p = 0.026), prior thrombosis (OR 22.15, 95%CI 2.11-232.27, p = 0.010), and prior stroke (OR 10.71, 95%CI 2.47-46.36, p = 0.002) were independently associated with cSVD, while individual aPL profiles were not. Conclusion cSVD is a common feature in patients with APS and often occurs in the absence of neurological manifestations. The predominance of lacunes suggests a pattern of recurrent microvascular injury. Hypertension and thrombotic history are major contributors, underscoring the need for comprehensive vascular risk assessment. These findings highlight the potential value of MRI screening in selected patients with APS and call for longitudinal studies to clarify its prognostic significance.