Genetic and lifestyle risk factors for MRI-defined brain infarcts in a population-based setting

Objective To explore genetic and lifestyle risk factors of MRI-defined brain infarcts (BI) in large population-based cohorts. Methods We performed meta-analyses of genome-wide association studies (GWAS) and examined associations of vascular risk factors and their genetic risk scores (GRS) with MRI-defined BI and a subset of BI, namely, small subcortical BI (SSBI), in 18 population-based cohorts (n = 20,949) from 5 ethnicities (3,726 with BI, 2,021 with SSBI). Top loci were followed up in 7 population-based cohorts (n = 6,862; 1,483 with BI, 630 with SBBI), and we tested associations with related phenotypes including ischemic stroke and pathologically defined BI. Results The mean prevalence was 17.7% for BI and 10.5% for SSBI, steeply rising after age 65. Two loci showed genome-wide significant association with BI: FBN2, p = 1.77 × 10−8; and LINC00539/ZDHHC20, p = 5.82 × 10−9. Both have been associated with blood pressure (BP)–related phenotypes, but did not replicate in the smaller follow-up sample or show associations with related phenotypes. Age- and sex-adjusted associations with BI and SSBI were observed for BP traits (p value for BI, p[BI] = 9.38 × 10−25; p[SSBI] = 5.23 × 10−14 for hypertension), smoking (p[BI] = 4.4 × 10−10; p[SSBI] = 1.2 × 10−4), diabetes (p[BI] = 1.7 × 10−8; p[SSBI] = 2.8 × 10−3), previous cardiovascular disease (p[BI] = 1.0 × 10−18; p[SSBI] = 2.3 × 10−7), stroke (p[BI] = 3.9 × 10−69; p[SSBI] = 3.2 × 10−24), and MRI-defined white matter hyperintensity burden (p[BI] = 1.43 × 10−157; p[SSBI] = 3.16 × 10−106), but not with body mass index or cholesterol. GRS of BP traits were associated with BI and SSBI (p ≤ 0.0022), without indication of directional pleiotropy. Conclusion In this multiethnic GWAS meta-analysis, including over 20,000 population-based participants, we identified genetic risk loci for BI requiring validation once additional large datasets become available. High BP, including genetically determined, was the most significant modifiable, causal risk factor for BI.


Introduction
Brain infarcts (BI) detected on MRI are commonly seen in older persons, being described in 8%-28% of participants in population-based cohort studies. 1 Most MRI-defined BI are covert, not being associated with overt, clinical stroke symptoms. 2,3 Nonetheless, they cannot be considered silent or benign, as they are often associated with subtle neurologic symptoms and with increased risk of future stroke, cognitive decline, and in some studies dementia. 4,5 Most MRI-defined BI are small subcortical BI (SSBI), believed to be primarily caused by small vessel disease (SVD). 6 Mechanisms and predictors of BI and SSBI remain incompletely understood. No genetic risk variants for BI and SSBI have been consistently identified to date, [7][8][9][10][11][12][13][14][15][16] and findings with vascular risk factors have been inconsistent. 1 Partly reflecting this uncertainty, recommendations to direct clinicians on how to best manage covert MRI-defined BI are lacking.
To enhance understanding of risk factors for BI and SSBI, we first conducted a large meta-analysis of genome-wide association studies (GWAS) from 18 population-based studies, comprising 20,949 participants from 5 ethnic groups, using the 1000 Genomes reference panel (1000G), more than doubling the size of a prior GWAS. 16 Second, we examined the association of vascular risk factors with BI and SSBI in this large sample, using both vascular risk factor measurements and their genetic risk scores (GRS).

Study design and samples
The meta-analyses included 18 prospective population-based cohorts participating in the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) consortium (table e-1 and additional Methods e-1, doi.org/10.5061/ dryad.hk07677). Although the cohorts contributing participants are longitudinal, this study is cross-sectional, based on the analysis of BI and SSBI at one timepoint in the subset of cohort participants with brain MRI. These cohorts comprised 5 ethnic groups and ancestries: European (n = 17,956), African (n = 1,834), Hispanic (n = 737), Malay (n = 215), and Chinese (n = 207). Some cohorts contributed to data for more than one ethnic group, resulting in a total of 23 datasets (tables e-1 to e-3, doi.org/10.5061/dryad.hk07677). Out of a total of 20,949 participants, 3,726 had MRI-defined BI. We did not exclude participants with a history of overt, clinically defined stroke prior to the MRI, except in 4 cohorts where patients with history of stroke were excluded by design. Three datasets did not contribute to the SSBI analysis either due to small numbers or absence of BI subtyping. Out of a total of 19,073 participants in the remaining 20 datasets, 3,533 had BI, of whom 2,021 (57.2%) had SSBI.

Variable definitions
Detailed MRI scanning protocols, as well as BI and SSBI definitions, for each study are described in table e-4 (doi.org/ 10.5061/dryad.hk07677). All protocols comprised at least T1, T2, and proton density or fluid-attenuated inversion recovery (FLAIR) sequences. On MRI, BI were defined as an area of abnormal signal intensity lacking mass effect with a size ≥3-4 mm; in the white matter, they were required to be hypointense on T1-weighted images, approaching the hypointensity of CSF, to distinguish them from diffuse white matter lesions; and they were distinguished from dilated perivascular spaces based on their irregular shape, presence of a hyperintense rim in FLAIR, and absence of a typical vascular shape following the orientation of perforating vessels. 17 SSBI corresponded to BI with a size <15-20 mm, located in the basal ganglia, the white matter, or the brainstem. Participants with large BI or BI located in the cerebral cortex or cerebellum were excluded from analyses of SSBI. We also measured burden of white matter hyperintensities (WMH), a quantitative MRI marker of SVD, corresponding to signal abnormalities of variable size in the white matter, appearing as hyperintensity on T2-weighted or FLAIR images, but without cavitation. Details of WMH measurements have been described previously. 18 Vascular risk factors Vascular risk factor levels measured closest to brain MRI acquisition were used. Hypertension was defined as systolic blood pressure (SBP) ≥140 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg or use of one or more blood pressure (BP)-lowering medications. We defined pulse pressure (PP) as the difference between SBP and DBP and mean arterial pressure (MAP) as DBP + 1/3 × PP. Diabetes was defined as a previous diagnosis of diabetes, a fasting plasma glucose >7.0 mmol/L, or antidiabetic drug use. Fasting serum total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides were measured using enzymatic methods. Lowdensity lipoprotein (LDL) cholesterol was calculated using the Friedewald formula. Body mass index (BMI) was defined as the ratio of weight (kg) to the square of height (m). Active smoking was defined according to study-specific criteria. History of overt, clinically defined stroke and other cardiovascular events was based on ongoing surveillance prior to brain MRI acquisition in most studies since participant recruitment had started prior to the initial brain MRI. In studies that had brain MRI scanning at the initial visit, the history and examination at this visit were used to identify prior overt, clinically defined stroke. History of cardiovascular events included history of angina, myocardial infarction, cardiac bypass surgery, angioplasty, or peripheral vascular disease.
Genome-wide association analyses with BI and small subcortical BI For genome-wide association analyses with BI and SSBI, each study performed logistic regression under an additive genetic model after adjusting for age, sex, principal components of population stratification, and additional study-specific covariates, such as study site or family structure, as needed (additional Methods e-2, doi.org/10.5061/dryad.hk07677, for centralized quality control description). Our primary multiethnic GWAS meta-analysis was performed using MANTRA, based on a Bayesian framework. 20 In secondary analyses, we also ran the multiethnic GWAS meta-analysis with 2 alternative methods (additional Methods e-2, doi.org/10.5061/ dryad.hk07677): (1) using fixed effects inverse variance weighting with METAL 21,22 and (2) using the random effects meta-analysis model implemented in METASOFT. 23 During meta-analysis, genomic control correction was applied to the individual studies and ethnic-specific results to remove any residual inflation of association statistics. We did not observe any systematic inflation of association statistics (figure e-1, doi.org/10.5061/dryad.hk07677). Statistical measures from MANTRA, the primary meta-analysis method, were used to define genome-wide significance (Log 10 of Bayesian factor [L 10 BF] > 6) 24 and to choose single nucleotide Glossary 1000G = 1000 Genomes reference panel; BI = brain infarcts; BMI = body mass index; BP = blood pressure; DBP = diastolic blood pressure; FLAIR = fluid-attenuated inversion recovery; GRS = genetic risk scores; GWAS = genome-wide association studies; HDL = high-density lipoprotein; IS = ischemic stroke; IS-SVD = small vessel disease subtype of ischemic stroke; IVW = inverse-variance weighting; L 10 BF = Log 10 of Bayesian factor; LD = linkage disequilibrium; LDL = low-density lipoprotein; MAP = mean arterial pressure; PP = pulse pressure; SNP = single nucleotide polymorphism; SBP = systolic blood pressure; SSBI = small subcortical brain infarcts; SVD = small vessel disease; WMH = white matter hyperintensities. polymorphisms (SNPs) for follow-up (L 10 BF > 4.5) in either the BI or SSBI meta-analysis. Details of functional annotation of top loci are provided in additional Methods e-3 (doi.org/ 10.5061/dryad.hk07677).

Follow-up and extension
For follow-up and extension studies, genotypes imputed to the 1000G reference panel were available in most instances for in silico look-up of the selected risk variants. Three follow-up studies performed de novo genotyping of the top 6 loci (additional Methods e-1, doi.org/10.5061/dryad. hk07677). The lead variant (with lowest p value) was genotyped at each suggestive or genome-wide significant locus, and if not feasible, another variant in strong linkage disequilibrium (LD, r 2 > 0.8) was genotyped. A p value <0.0083, correcting for 6 loci, was considered significant evidence for replication.
The follow-up sample, in which we sought to confirm associations observed in the discovery analysis, included 6,862 participants, of whom 1,483 had BI and 630 had SSBI, from 6 community-based studies of European origin and one of Japanese origin (table e-1, doi.org/10.5061/dryad.hk07677).
As an extension, to test whether genetic variants associated with MRI-defined BI or SSBI in the discovery analysis are also associated with correlated phenotypes, we first explored their association with ischemic stroke (IS) overall and the small vessel disease subtype (IS-SVD) when available in 4 collaborative studies (table e-1, doi.org/10.5061/dryad.hk07677). Second, we explored whether genetic variants associated with MRI-defined BI and SSBI were associated with neuropathologically defined BI based on 2,940 brain autopsies in participants without dementia from the Alzheimer's Disease Genetics Consortium (ADGC). Participants with large infarcts or lacunes (n = 857, 29%) were compared to participants without any infarcts or having only microscopic infarcts (n = 2,083). 25 We calculated power of the follow-up and extension studies using Quanto V1.2.3 (biostats.usc.edu/software; table e-8 and figure e-2, doi.org/10.5061/dryad.hk07677).

Association of vascular risk factors with BI and SSBI
Individual studies performed logistic regression to test for association of vascular risk factor measurements with presence or absence of at least one BI or SSBI. Analyses were performed with and without adjustments for age and sex. Analyses with BP or lipid traits as the main independent variable were additionally adjusted for treatment with diseasespecific medications, and association analyses with fasting plasma glucose were limited to participants without type 2 diabetes. Except for WMH burden, the regression coefficients and standard errors for risk factors in the individual studies belonging to one ethnic group were combined using fixed-effects inverse variance-weighted meta-analysis and subsequently the betas and standard errors obtained in each ethnic group were combined using fixed-effects inverse variance-weighted meta-analysis, in the absence of heterogeneity (p < 1 × 10 −6 ), to derive the multiethnic meta-analysis estimates. For WMH burden, the statistics were combined using the Z score-based sample size weighted meta-analysis as WMH burden was measured on different scales in participating studies. 18 We then explored whether genetic variants previously shown in published GWAS to be associated with specific vascular risk factors were, in aggregate, also associated with BI and SSBI. This approach was selected to assess to what extent genetically determined vascular risk factor levels are associated with BI and SSBI and to provide evidence for a causal relation between a given vascular risk factor and risk of BI or SSBI, provided that Mendelian randomization assumptions are fulfilled. 26 We combined known genetic risk variants for each individual vascular risk factor into a weighted GRS, using effect estimates from the largest published GWAS of that risk factor as weights. We then tested for association of these GRS with BI and SSBI using the inverse-variance weighting (IVW) method. Construction of the GRS, selection of variants for the GRS analysis, as well as effect estimates used as weights are detailed in additional Methods e-4 and tables e-9-e-12 (doi.org/10. 5061/dryad.hk07677). For significant GRS associations with BI or SSBI, we further conducted sensitivity analyses using the MR-Egger method implemented as an R package (TwoSampleMR), 27 which unlike the IVW method estimates the intercept term as part of the analysis. An intercept term significantly differing from zero suggests the presence of directional (unbalanced) pleiotropy, meaning that the pleiotropic effects of genetic variants are not balanced about the null. 27 We used a conservative significance threshold of p < 0.05 for the intercept.
After Bonferroni correction for 12 independent vascular phenotypes tested for association with BI and SSBI, p < 0.0042 was considered significant for associations with vascular risk factor measurements or GRS. The number of independent vascular phenotypes, taking into account correlation between the phenotypes considered, was estimated based on individual level data from the 3C-Dijon study using the online tool matSpDlite (neurogenetics.qimrberghofer.edu.au/matSpDlite/).

Standard protocol approvals, registrations, and patient consents
Institutional review boards approved all of these studies, and all participants provided informed consent.

Data availability
Summary statistics of the top SNPs are available from Dryad for both BI and SSBI. Other data that support the findings of this study are available from the corresponding authors upon reasonable request.

Results
In this large population-based dataset comprising 18 cohort studies, the frequency of MRI-defined BI ranged from 4% to 38% in participating cohorts (table e-1, doi.org/10.5061/ dryad.hk07677). A description of demographic characteristics in all participants with BI (n = 3,726), with SSBI (n = 2,021), and without BI (n = 17,223) is provided in tables e-2 and e-3 (doi.org/10.5061/dryad.hk07677) for individual studies. Participants with BI and SSBI were on average 6 years older and more often men compared to those without BI. In agestratified analyses, the prevalence of BI and SSBI increased with age, most prominently beyond age 65, after which a 25.8% (range 13.9%-37.0%) increment in BI prevalence was observed compared to participants younger than 65 years (figure 1). Overall, the prevalence of BI ranged from less than 5% before age 50 to over 30% beyond age 80, with similar findings when we analyzed men and women separately (figures e-3 and e-4, doi.org/10.5061/dryad.hk07677). Only 11% of those with BI and 9% of those with SSBI had a history of stroke (12.5% and 9.8% when removing cohorts that excluded participants with history of stroke by design); hence, the vast majority of MRI-defined BI were covert.
In the substantially smaller population-based follow-up studies, we could not replicate the 2 genome-wide significant or the 4 suggestive loci associated with BI or SSBI (table  2). Of the 6 loci that we followed up, we had limited power for 2 of the loci for BI (52%) and 4 of the loci for SSBI (50%-58%) (table e-8, doi.org/10.5061/dryad.hk07677). Power estimates in the follow-up study are even lower when accounting for the winner's curse phenomenon, which leads to inflated effect estimates in the discovery cohort. 28 One suggestive locus for SSBI (PLEKHG1) showed nominal association with BI and SSBI in the follow-up studies (p BI = 0.03 and p SSBI = 0.02), but in the opposite direction (table 2).
Likewise, none of the genome-wide significant or suggestive loci for BI and SSBI showed association with IS (overall or IS-SVD) or pathologically defined BI in the extension studies after correcting for multiple testing (table 2 and table e-14, doi.org/10.5061/dryad.hk07677). Whereas the sample size Figure 1 Prevalence of MRI-defined brain infarcts (BI) and small subcortical brain infarcts (SSBI) by different age groups CI = confidence interval. Table 1 Loci reaching Log 10 of Bayesian factor (L 10 BF) >4.5 in the discovery stage of the genome-wide association studies with brain infarcts (BI) or small subcortical brain infarcts (SSBI)  Abbreviations: BI = brain infarcts; CI = confidence interval; OR = odds ratio; SNP = single nucleotide polymorphism; SSBI = small subcortical brain infarcts. Values are OR (95% CI) with respect to the minor allele followed by p value of association. a For ischemic stroke, meta-analysis results of METASTROKE-IS, CHARGE-IS, and SiGN-IS are presented. For ischemic stroke due to small vessel disease, meta-analysis results of METASTROKE-IS-SVD, Young Lacunar Stroke DNA Resource-SVD, and SiGN-IS-SVD are presented. b Data presented for the following SNPs are for their proxies: rs75889566 = rs902393 (r 2 = 0.96), rs12583648 = rs12584792 (r 2 = 0.96), rs74587705 = rs7170681 (r 2 = 0.67).
for overall IS and IS-SVD was relatively large, it was limited for pathologically defined BI, and power was insufficient for 4 of the loci (25%-70%) ( When exploring the relation of weighted genetic risk scores for vascular risk factors with BI and SSBI, we found that GRS for SBP and MAP were significantly associated with increased risk of BI and SSBI after correction for multiple testing (table 4). In sensitivity analyses using MR-Egger regression, evidence for directional pleiotropy was lacking for these associations between SBP or MAP GRS and BI or SSBI (p intercept >0.36). GRS for DBP, BMI, coronary artery disease, WMH burden, and IS were nominally associated with BI (p < 0.05, table 4), but these associations did not survive correction for multiple testing.

Discussion
This multiethnic meta-analysis comprising over 20,000 community participants provides noteworthy insight into risk factors for MRI-defined brain infarcts. The described BI distributions across different age groups and by sex may also serve as a reference for comparison with BI and SSBI frequency in other settings. Of note, about 90% of BI were covert, not being associated with a history of stroke. In this multiethnic GWAS of BI and SSBI, we identified 2 genomewide significant risk loci for BI, FBN2 on chr5q23 and LINC00539/ZDHHC20 on chr13q12, although these could not be replicated in a smaller follow-up sample. We further describe the association of MRI-defined BI with vascular risk factors, combining the vast majority of population-based cohort studies with BI and SSBI measurements available. We find high BP, both phenotypically expressed high BP and genetically determined risk for high BP, to be the most significant modifiable risk factor for BI. No association with cholesterol levels or BMI was found.
To identify novel genetic risk loci for MRI-defined BI and SSBI, we have more than doubled the sample size compared to the previously published GWAS of MRI-defined BI, 16 used imputed genotypes based on the 1000G reference panel to increase the marker coverage, and included samples from 5 ethnicities for a broader representation of individuals from different origins. Moreover, we studied both BI and SSBI, while only BI were analyzed in the previously published GWAS metaanalysis. 16 Our inability to replicate the genome-wide significant and suggestive findings could reflect false-positive results but may also be explained by insufficient power in the follow-up stage (table e-8, doi.org/10.5061/dryad.hk07677). Further studies on larger samples with MRI-defined BI are required to confirm or refute these findings. Moreover, while we could not provide evidence for an association of genome-wide significant and suggestive risk loci for BI and SSBI with IS, IS-SVD, or pathologically defined BI, this inability could reflect differences in the biology underlying these phenotypes, as well as limited power in the extension studies.
The 2 loci that crossed the genome-wide significance threshold, while requiring confirmation in larger independent samples, do harbor plausible biological candidates. Fibrillin2 (FBN2) encodes a protein that is part of the connective tissue microfibrils and elastic fiber assembly of the cell. 29 Rare and common variants in FBN2 have been associated with agerelated macular degeneration. 30 Recent studies have also implicated common variants in FBN2 to be associated with SBP, 31 although the variants differ (rs6595838-SBP and rs39938-BI, r 2 = 0.017). The LINC00539/ZDHHC20 locus was a suggestive hit in a GWAS of adverse metabolic response to hydrochlorothiazide, a drug commonly used to treat hypertension. 32 The lead SNP in the region could also influence the expression of the long noncoding RNA LINC00539 (table e-17, doi.org/10.5061/dryad.hk07677).
Our findings provide definitive evidence for a major and predominant association of increasing BP levels with increased risk of BI and SSBI. 1,33 Beside significant associations with hypertension, a continuous association was observed for increasing levels of all BP measurements (SBP, DBP, PP, MAP), consistent with elevated BP being the major modifiable risk factor for BI, as is the case for overt, clinically defined IS. [34][35][36] The importance and causal nature of the relation between high BP and risk of BI and SSBI is further supported by the significant association of BP genetic risk scores, for SBP and MAP, with increased risk of BI, especially SSBI, with no indication of directional pleiotropy using the MR-Egger approach. 27 Previous publications on the association of BI and SSBI with vascular risk factors other than elevated BP were inconsistent. 1,33,37 Our study provides evidence for a significant association of current smoking and diabetes with risk of Abbreviations: BMI = body mass index; CI = confidence interval; CVD = cardiovascular disease; HDL = high-density lipid; LDL = low-density lipid; OR = odds ratio; p-het = p for heterogeneity; WMH = white matter hyperintensity. a All association analyses presented were adjusted for sex and age and meta-analyses estimates presented are from fixed effects inverse variance weighted meta-analyses, except for WMH burden. Association analyses for blood pressure factors were additionally adjusted for usage of blood pressure-lowering drugs. Association analyses for lipid factors were additionally adjusted for usage of lipid-lowering drugs. Association analysis for glucose was performed only on participants without type 2 diabetes. b Associations significant after correcting for the number of independent phenotypes (n = 12, p < 0.0042). c Meta-analyses for WMH burden were performed using sample size weighted meta-analysis, which yielded Z scores as effect estimates and not ORs with CIs; this is because WMH burden was measured on different scales in participating studies (quantitative measures in mL in all but 2 studies and semiquantitative measures on a 10-grade scale in the Atherosclerosis Risk in Communities study and the Cardiovascular Health Study [Additional Methods 1, doi.org/10.5061/dryad.hk07677]).
BI and SSBI, while no association with BMI and cholesterol could be demonstrated, despite the very large sample size. These findings are consistent with epidemiologic data on IS. 35 Interestingly, in contrast with cholesterol levels, a significant association of increasing triglyceride levels with BI risk was observed, although for SSBI the association did not withstand correction for multiple testing. Inconsistent results have been reported regarding association of triglycerides with overt, clinically defined IS, 38,39 but the present results are in line with evidence of an association in older community-dwelling persons between high triglyceride levels and WMH burden, another MRI marker of SVD. 40 As previously described, we show a significant association of WMH burden with BI and SSBI, reaching p < 10 −100 in this study. Surprisingly, shared genetic variation among the top loci for WMH burden and BI was limited. While this observation could be due to lack of power, it could also suggest that WMH and BI share more environmental than genetic risk factors. A more comprehensive search for shared genetic variation between WMH burden and BI or SSBI at the genome-wide level using the LD score regression method 41 could not be performed in the present study due to low variance in the BI GWAS, also hampering the calculation of BI heritability using the same method. Of note, based on estimates from previously published family-based studies, heritability for SSBI was described to be low at 29%, in contrast with a moderate to high heritability for WMH burden at 49%-80%. [42][43][44] Hypertension is a major risk factor for WMH as well, and a BP GRS was also significantly associated with WMH burden in a prior study. 18 Table 4 Association of genetic risk scores (GRS) for vascular risk factors with brain infarcts and small subcortical brain infarcts However, the association of WMH burden with BI and SSBI was still significant after adjusting for hypertension status ( An important strength of the present study is that we have gathered nearly all large population-based studies with MRI-based identification of BI, genome-wide genotypes, and detailed vascular risk factor and comorbidity assessment, totaling over 20,000 participants covering 5 ethnic groups. Despite the unprecedented sample size, we were underpowered for the discovery of novel, robust genetic risk loci and even more so for the follow-up of genome-wide significant findings. Our ability to discover robust genetic risk variants may also have been hampered by the heterogeneity in BI and SSBI etiology, even though SVD is likely the predominant mechanism, 45 and by some heterogeneity in the way BI and SSBI have been measured in participating studies. Finally, although the majority of participants had covert BI, 10% had a history of overt, clinically defined stroke, but including both covert and overt BI also enables a better representation of the spectrum of participants with MRI-defined BI in the general population. Whereas history of stroke was more common in participants with BI than those without, we do not believe that this inclusion has driven the associations we observed, given both the small number of participants with a stroke history and the significance level of the observed associations. Moreover, in this population-based setting, determining whether an MRI-defined BI could be attributed to the history of clinically defined stroke was not always possible.
In clinical practice, MRI-defined BI are commonly seen on brain MRI scans performed for various reasons in older persons. They have been shown to be powerful predictors of incident stroke and incident dementia. 1,4,46 Hence BI represent an important marker for detection of high-risk individuals and initiation of preventive interventions. However, no randomized trials and no recommendations are currently available for the management of covert MRI-defined BI. The observational evidence is overwhelming for a strong causal relation between high BP and risk of BI and SSBI. A randomized trial will be needed to decide if persons with MRI-defined BI will benefit from more intensive BP-lowering strategies than is recommended currently for primary prevention.
This multiethnic, population-based study on 20,949 participants sheds important new light on susceptibility factors of MRI-defined brain infarcts, a marker of covert vascular brain injury commonly observed in older persons.