Microbleeds in the Secondary Prevention of Small Subcortical Strokes Trial: Stroke, mortality, and treatment interactions

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Cerebral microbleeds (CMBs) are remnants of prior cerebral microhemorrhages at the level of arterioles and capillaries visualized on blood‐sensitive magnetic resonance imaging (MRI) sequences.1 CMBs have evolved as radiological markers of cerebral small vessel disease (CSVD), representing, most notably, hypertensive arteriopathy (arteriolosclerosis) and/or cerebral amyloid angiopathy (CAA).2 CMB prevalence is highest in stroke subtypes associated with CSVD and strongly tied to hypertension.3 Previous studies characterizing CMBs in lacunar stroke have observed prevalence rates ranging from 23 to 54%,3 with higher prevalence observed within East Asian populations.
CMBs may have important clinical implications as predictors of recurrent stroke and mortality.11 Data also suggest that stroke patients with CMBs may respond differently to secondary stroke preventative therapies.15 However, the therapeutic effect of stroke preventive therapies in patients with CMBs has yet to be reported from a randomized controlled trial. Moreover, methodological limitations, imposed by observational design, small sample sizes, and/or absence of clear classification of stroke subtype, hamper our current understanding of CMBs in lacunar stroke and the independent contribution of CMBs to the aforementioned outcomes beyond simply marking underlying CSVD.
Accordingly, we sought to characterize CMBs in a well‐defined population with symptomatic CSVD by examining lacunar stroke patients within the Secondary Prevention of Small Subcortical Strokes (SPS3) trial and to assess the relationship between CMBs and recurrent stroke and death, as well as response to assigned treatments. We hypothesized that lacunar stroke patients with CMBs would have higher rates of recurrent stroke and death during follow‐up and that they would benefit more from aggressive blood pressure management.

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