Association of Brain Age, Lesion Volume, and Functional Outcome in Patients With Stroke

Abstract

BACKGROUND AND OBJECTIVES: Functional outcomes after stroke are strongly related to focal injury measures. However, the role of global brain health is less clear. Here, we examined the impact of brain age, a measure of neurobiological aging derived from whole brain structural neuroimaging, on post-stroke outcomes, with a focus on sensorimotor performance. We hypothesized that more lesion damage would result in older brain age, which would in turn be associated with poorer outcomes. Related, we expected that brain age would mediate the relationship between lesion damage and outcomes. Finally, we hypothesized that structural brain resilience, which we define in the context of stroke as younger brain age given matched lesion damage, would differentiate people with good versus poor outcomes. METHODS: We conducted a cross-sectional observational study using a multi-site dataset of 3D brain structural MRIs and clinical measures from ENIGMA Stroke Recovery. Brain age was calculated from 77 neuroanatomical features using a ridge regression model trained and validated on 4,314 healthy controls. We performed a three-step mediation analysis with robust mixed-effects linear regression models to examine relationships between brain age, lesion damage, and stroke outcomes. We used propensity score matching and logistic regression to examine whether brain resilience predicts good versus poor outcomes in patients with matched lesion damage. RESULTS: We examined 963 patients across 38 cohorts. Greater lesion damage was associated with older brain age (β=0.21; 95% CI 0.04,0.38, P=0.015), which in turn was associated with poorer outcomes, both in the sensorimotor domain (β=-0.28; 95% CI: -0.41,-0.15, P<0.001) and across multiple domains of function (β=-0.14; 95% CI: -0.22,-0.06, P<0.001). Brain age mediated 15% of the impact of lesion damage on sensorimotor performance (95% CI: 3%,58%, P=0.01). Greater brain resilience explained why people have better outcomes, given matched lesion damage (OR=1.04, 95% CI: 1.01,1.08, P=0.004). CONCLUSIONS: We provide evidence that younger brain age is associated with superior post-stroke outcomes and modifies the impact of focal damage. The inclusion of imaging-based assessments of brain age and brain resilience may improve the prediction of post-stroke outcomes compared to focal injury measures alone, opening new possibilities for potential therapeutic targets.