Small vessel disease burden and response to induced hypertension therapy in small vessel occlusion stroke with early neurological deterioration

Background: Induced hypertension therapy (iHT) is used to rescue early neurological deterioration (END) in small vessel occlusion (SVO) stroke. However, underlying perforator dysfunction reflected by small vessel disease (SVD) burden may attenuate its therapeutic effect. Aim: To investigate whether white matter hyperintensity (WMH) volume and total SVD score are associated with neurological response to iHT. Methods: Consecutive patients with acute SVO stroke who developed END and received iHT were identified from a prospective registry (January 2017–July 2025). Regional WMH volumes were quantified on magnetic resonance imaging fluid-attenuated inversion recovery images. Outcomes included early neurological improvement (ENI) following iHT and 3-month modified Rankin Scale (mRS). Associations were evaluated using binary and ordinal logistic regression. Results: Among 178 patients (median age, 68 years; 55.6% men), 93 (52.2%) achieved ENI. Higher WMH volumes were independently associated with a lower likelihood of ENI (odds ratio (OR) per twofold increase [95% confidence interval]: total, 0.57 [0.43–0.76]; periventricular, 0.57 [0.43–0.76]; deep, 0.68 [0.54–0.86]). Periventricular WMH volume was also associated with an unfavorable shift in 3-month mRS (common OR, 0.80 [0.65–0.99]). Increasing total SVD score was associated with worse 3-month mRS shift (common OR, 0.61 [0.43–0.85]) and a non-significant trend against ENI (OR, 0.70 [0.48–1.01]; p = 0.056). Conclusion: Greater SVD burden was associated with a poorer neurological response to iHT in SVO stroke with END. Imaging markers of SVD may help identify patients less likely to achieve neurological improvement following iHT, suggesting a need for alternative individualized rescue strategies.