Background Cerebral small‐vessel disease encompasses a spectrum of magnetic resonance imaging features reflecting microvascular pathology in ischemic stroke. Among these, white matter hyperintensities (WMHs) and cerebral microbleeds (CMBs) are the most widely studied. While both are well established as risk factors for cognitive decline in patients with acute ischemic stroke (AIS), their prognostic value for vascular events and death after AIS remains unclear. This study aims to evaluate WMH and CMB as predictors of recurrent stroke, cardiovascular death, and all‐cause death in patients with AIS. Methods We systematically searched PubMed and Embase for longitudinal studies from July 1977 to March 2024 reporting adjusted hazard ratios (HRs) or odds ratios for these outcomes after AIS. Pooled estimates were generated using random‐effects models, and heterogeneity was explored using meta‐regression and prediction intervals. Results Fifty studies (n=44 140) were included. WMHs were a significant predictor of stroke recurrence (HR,1.72 95% CI, 1.39–2.13) and all‐cause death (HR, 1.58 95% CI, 1.11–2.23). Similarly, CMBs were associated with stroke recurrence (HR, 1.88 95% CI, 1.52–2.33), with lobar and mixed types conferring higher risk than deep CMBs, and predicted cardiovascular death (HR, 1.45 95% CI, 1.2–1.75). For stroke recurrence, risk estimates increased in parallel with WMH and CMB burden. Conclusions This meta‐analysis supports WMHs and CMBs as independent predictors of stroke recurrence and death in AIS. Burden and distribution further refine prognostic accuracy and inform poststroke risk assessment.
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