BACKGROUND: Remote diffusion-weighted imaging lesions (RDWILs) in the context of spontaneous intracerebral hemorrhage (ICH) are associated with an increased risk of recurrent stroke, worse functional outcome, and death. To update current knowledge on RDWILs, we conducted a systematic review and meta-analysis of the prevalence, associated factors and presumed causes of RDWILs. METHODS: We searched Pubmed, Embase, and Cochrane up to June 2022 for studies reporting RDWILs in adults with symptomatic ICH of no-identified-cause, assessed by magnetic resonance imaging, and analyzed associations between baseline variables and RDWILs in random-effects meta-analyses. RESULTS: Eighteen observational studies (7 prospective), reporting 5211 patients were included, of whom 1386 had ≥1 RDWIL (pooled prevalence: 23.5% [19.0–28.6]). RDWIL presence was associated with neuroimaging features of microangiopathy, atrial fibrillation (odds ratio, 3.67 [1.80–7.49]), clinical severity (mean difference in National Institutes of Health Stroke Scale score, 1.58 points [0.50–2.66]), elevated blood pressure (mean difference, 14.02 mmHg [9.44–18.60]), ICH volume (mean difference, 2.78 mL [0.97–4.60]), and subarachnoid (odds ratio, 1.80 [1.00–3.24]) or intraventricular (odds ratio, 1.53 [1.28–1.83]) hemorrhage. RDWIL presence was associated with poor 3-month functional outcome (odds ratio, 1.95 [1.48–2.57]). CONCLUSIONS: RDWILs are detected in approximately 1-in-4 patients with acute ICH. Our results suggest that most RDWILs result from disruption of cerebral small vessel disease by ICH-related precipitating factors such as elevated intracranial pressure and cerebral autoregulation impairment. Their presence is associated with worse initial presentation and outcome. However, given the mostly cross-sectional designs and heterogeneity in study quality, further studies are needed to investigate whether specific ICH treatment strategies may reduce the incidence of RDWILs and in turn improve outcome and reduce stroke recurrence.

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