MRI markers of cerebral small vessel disease prior to first-ever spontaneous intracerebral hemorrhage: a retrospective case–control study

Cerebral small vessel disease (CSVD) is a major contributor to stroke, cognitive decline, and intracerebral hemorrhage (ICH). While post-ICH MRI markers of CSVD are well described, their role in predicting first-ever ICH remains unclear. We conducted a retrospective case–control study at a tertiary stroke center, including patients with first-ever spontaneous ICH between 2012 and 2024 who had a prior brain MRI, with controls frequency-matched by age and sex. 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 logistic regression. Altogether, of 2,734 ICH cases, 63 met inclusion criteria and were compared with 63 controls (age 68 ± 13 years). The median interval between MRI and ICH was 14.6 months (IQR 8.3–29.5). In adjusted analyses, any CMB (OR 10.96, 95% CI 4.00–30.02), PVS > 20 in either region (OR 4.31, 1.52–12.22), and WMH (OR 2.60, 1.21–5.60) were associated with ICH. In a multivariable model, CMB (OR 10.50,95% CI 3.63–30.42) remained independently associated with ICH, whereas PVS > 20 did not reach significance (OR 3.35, 0.95–11.75). Acute CMI showed a suggestive association based on few cases (5/63 vs. 0/63). MRI-defined CSVD markers on pre-ICH scan were associated with first-ever ICH. The present study is the first to describe the association between CMI and future ICH risk. Brain imaging may help identify high-risk patients and guide preventive strategies.