Picture this: you’re solving a complex puzzle and suddenly, you stumble upon a hidden compartment that reveals another puzzle inside. That’s the kind of brain teaser researchers encountered when investigating simultaneous multiple intracerebral hemorrhage (SMICH). In this study, they aimed to determine the main type of cerebral small vessel disease (SVD) that underlies SMICH and its impact on patient outcomes. By analyzing patient data, they found that hypertensive-SVD was the predominant angiopathy in most SMICH cases. However, a subgroup with undetermined-etiology SMICH displayed a higher burden of deep cerebral microbleeds and distinct imaging features. These intriguing findings hint at an underlying microangiopathy exclusive to the undetermined-etiology group. Additionally, patients with SMICH were at a significantly higher risk of experiencing poor outcomes. This study sheds light on the intricate relationship between microangiopathy, SVD, and SMICH, providing valuable insights for future research on preventing and managing this challenging condition. If you’re intrigued by the mysteries of the brain and want to delve deeper into this fascinating study, check out the link below!

ObjectiveTo identify the predominant type of cerebral small vessel disease (SVD) and outcomes in patients with simultaneous multiple intracerebral hemorrhages (SMICH).MethodsConsecutive patients with intracerebral hemorrhage (ICH) from a single-center prospective cohort were retrospectively reviewed. Presumed etiology was classified according to the SMASH-U criteria. Demographics, clinical and laboratory variables, and neuroimaging data were compared between patients with primary SMICH and those with single ICH. Functional outcomes were assessed using the modified Rankin scale 90 days after ICH.ResultsOf the 598 enrolled patients, 37 (6.2%) met the criteria for SMICH. Risk factors for SMICH included a high burden of deep cerebral microbleeds (CMBs) (odds ratio [OR] 1.06, 95% confidence interval [CI], 1.00–1.12; p = 0.040), white matter hyperintensity scores (OR 1.27, 95% CI 1.04–1.57; p = 0.021), history of ICH (OR 3.38, 95% CI 1.31–8.05; p = 0.008), and low serum magnesium levels (OR 0.01, 95% CI 0.00–0.25; p = 0.007). Based on the SMASH-U classification, 15(40.5%) SMICH were classified as hypertension, whereas 17 (45.9%) as undetermined-etiology. To further explore the potential microangiopathy underlying undetermined-SMICH, these patients with undetermined-etiology were compared to those with cerebral amyloid angiopathy-ICH, and were associated with a higher burden of deep CMBs but less severe centrum semiovale enlarged perivascular spaces. Likewise, compared with hypertension-ICH patients, those with undetermined SMICH were consistently associated with a higher deep CMB counts. Moreover, multivariate analysis revealed that SMICH was independently associated with poor outcomes (OR 2.23, 95%CI 1.03–4.76; p = 0.038).ConclusionOur results suggest that most patients with primary SMICH harbor hypertensive-SVD as principal angiopathy. Patients with SMICH are at a high risk of poor outcomes. (ClinicalTrials.gov Identifier: NCT 04803292).

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