Comparative diagnostic and prognostic performance of SWI and T2-Weighted MRI in cerebral microbleed detection following acute ischemic stroke: a meta-analysis and SPOT-CMB study

Background and Objectives: Cerebral microbleeds (CMBs) are increasingly being considered as potential biomarkers of small vessel disease and cerebral vulnerability, particularly in patients with acute ischemic stroke (AIS). Accurate detection is crucial for prognosis and therapeutic decision-making, yet the relative utility of susceptibility-weighted imaging (SWI) versus T2*-weighted imaging (T2*) remains uncertain. Materials and Methods: We conducted a systematic review and meta-analysis (SPOT-CMB, Susceptibility-weighted imaging and Prognostic Outcomes in Acute Stroke—Cerebral Microbleeds study) of 80 studies involving 28,383 AIS patients. Pooled prevalence of CMBs was estimated across imaging modalities (SWI, T2*, and both), and stratified analyses examined variation by demographic, clinical, and imaging parameters. Meta-analytic odds ratios assessed associations between CMB presence and key outcomes: symptomatic intracerebral hemorrhage (sICH), hemorrhagic transformation (HT), and poor functional outcome (modified Rankin Scale score 3–6) at 90 days. Diagnostic performance was assessed using summary receiver operating characteristic curves. Results: Pooled CMB prevalence was higher with SWI (36%; 95% CI 31–41) than T2* (25%; 95% CI 22–28). CMB presence was associated with increased odds of sICH (OR 2.22; 95% CI 1.56–3.16), HT (OR 1.33; 95% CI 1.01–1.75), and poor 90-day outcome (OR 1.61; 95% CI 1.39–1.86). However, prognostic performance was modest, with low sensitivity (e.g., AUC for sICH: 0.29) and low diagnostic odds ratios. SWI outperformed T2* in detection but offered limited prognostic gain. Access to SWI remains limited in many settings, posing challenges for global implementation. Conclusions: SWI detects CMBs more frequently than T2* in AIS patients and shows stronger associations with adverse outcomes, supporting its value for risk stratification. However, prognostic accuracy remains limited, and our GRADE appraisal indicated only moderate certainty for functional outcomes, with lower certainty for diagnostic accuracy due to heterogeneity and imprecision. These findings highlight the clinical utility of SWI but underscore the need for standardized imaging protocols and high-quality prospective studies.