To determine whether hypertensive cerebral small vessel disease (HTN-cSVD) is the underlying microangiopathy of deep (white matter, deep nuclei, cerebellar peduncle) cerebellar intracerebral hemorrhage (cICH).

Superficial (gray matter, vermis) cICH is associated with strictly lobar supratentorial cerebral microbleeds (CMBs)—a marker for cerebral amyloid angiopathy. We hypothesized that left ventricular hypertrophy (LVH), a marker for HTN-cSVD, and non-hemorrhagic markers of HTN-cSVD (peri-basal ganglia [BG] white matter hyperintensity [WMH] pattern, deep lacunes, and severe BG enlarged perivascular spaces [EPVS]) would be associated with deep vs. superficial cICH.

Brain MRIs from consecutive non-traumatic ICH patients admitted to a referral center (2003 to 2019) were reviewed for CMBs and non-hemorrhagic markers. Clinical risk factors, LVH, and neuroimaging markers were compared between deep and superficial cICH patients in univariate/multivariable models.

Of 1,791 patients with ICH, 129 (7%) were found to have cICH (mean age 73±12 years, 46% female). Of these, 83 (64%) had deep cICH and 46 (36%) had superficial cICH. Hypertension (94% vs. 67%, p < 0.01) and LVH (60% vs. 28%, p < 0.01) were more common among patients with deep cICH. Among those with MRIs (74%), the frequency of peri-BG WMH pattern (24% vs. 5%, p = 0.02), deep lacunes (59% vs. 14%, p < 0.01), severe BG EPVS (27% vs. 3%, p < 0.01), deep CMBs (51% vs. 16%, p < 0.01), and mixed-location CMBs (37% vs. 11%, p < 0.01) was greater among deep cICH patients. When entered into a multivariable regression, LVH (OR 3.10, 95% CI [1.07–8.97], p = 0.04) and deep lacunes (OR 4.38, 95% CI [1.25–15.31], p = 0.02) remained significantly associated with deep cICH.

Because supratentorial HTN-cSVD markers are common in deep cICH, and deep lacunes and LVH are independently associated with deep cICH, it is likely that HTN-cSVD is the underlying microangiopathy of deep cICH.