Association between post-treatment neuroimaging markers of cerebral small vessel disease and short-term efficacy of recombinant tissue plasminogen activator in acute stroke patients

INTRODUCTION: Cerebral small vessel disease (CSVD) is prevalent in acute ischemic stroke (AIS) and may influence outcomes following intravenous thrombolysis with recombinant tissue plasminogen activator (r-tPA). This study examined associations between CSVD neuroimaging markers and early treatment response, defined as ≥4-point improvement on the National Institutes of Health Stroke Scale (NIHSS) at 24-48 hours. METHODS: In this retrospective cohort study at a tertiary stroke center (August 2020-November 2021), 154 AIS patients receiving r-tPA within 4.5 hours of onset underwent MRI within 48 hours after thrombolysis.CSVD markers (cerebral microbleeds [CMBs], lacunar infarcts, white matter hyperintensities [WMHs], enlarged perivascular spaces [EPVSs]) were assessed per STRIVE-2 standards, with total CSVD burden scored 0-4. Univariate and multivariable logistic regression analyzed associations with treatment response, adjusting for baseline NIHSS, sex, dyslipidemia, and visible infarction. CONCLUSIONS: Among CSVD markers, only CMBs were associated with poorer early r-tPA response in AIS. Given the retrospective design, small number of CMB-positive patients, and use of post-treatment MRI, these findings should be considered hypothesis-generating. Future prospective studies with pre-treatment and serial imaging are warranted.