Skip to main content

Advertisement

SpringerLink
Log in

Rapid Blood Pressure Reduction in Acute Intracerebral Hemorrhage: Feasibility and Safety

  • Practical Pearl
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Background

The optimal blood pressure (BP) for treating acute intracerebral hemorrhage remains (ICH) uncertain. High BP may contribute to hematoma growth while excessive BP reduction might precipitate peri-hemorrhage ischemia. We examine here the feasibility and safety of reducing BP to lower than presently recommended levels in patients with acute ICH.

Methods

Patients with ICH were prospectively randomized to standard BP treatment (mean arterial BP [MAP] 110–130 mmHg) or aggressive BP lowering (MAP < 110 mmHg) within 8 h of symptom onset. MAP was managed during the 48 h treatment period. NIHSS was obtained at baseline, 24, and 48 h. Brain CT was done 24 h after symptoms. A modified Rankin Scale (mRs) was obtained at 90 days. A clinical decline (NIHSS drop ≥ 2 points) within the first 48 h was the primary endpoint. Hematoma enlargement at 24 h was a secondary endpoint.

Results

We enrolled 21 patients into each group. Mean age was 60.6 ± 12.3 years and MAP on presentation was 147.6 ± 18.2 mmHg. Treatment was started on average 3.2 ± 2.2 h after symptom onset. Baseline clinical variables were identical between the 2 treatment groups. Target blood pressure was achieved within 87.1 ± 59.6 min in the standard group and 163.5 ± 163.8 min in the aggressive BP treatment group. There were no significant differences in early neurological deterioration, hematoma and edema growth, and clinical outcome at 90 days.

Conclusion

A more aggressive reduction of acute hypertension after ICH does not increase the rate of neurological deterioration even when treatment is initiated within hours of symptom onset. Lowering BP aggressively did not affect hematoma and edema expansion but this possibility deserves further study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Broderick JP, Adams HP Jr., Barsan W, Feinberg W, Feldmann E, Grotta J, Kase C, Krieger D, Mayberg M, Tilley B, Zabramski JM, Zuccarello M. Guidelines for the management of spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a special writing group of the stroke council, American Heart Association Stroke 1999;30(4):905–15.

    PubMed  CAS  Google Scholar 

  2. Priorities for clinical research in intracerebral hemorrhage: report from a National Institute of Neurological Disorders and Stroke Workshop. Stroke 2005;36(3):e23–41.

    Google Scholar 

  3. Brott T, Broderick J, Kothari R, Barsan W, Tomsick T, Sauerbeck L, Spilker J, Duldner J, Khoury J. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 1997;28(1):1–5.

    PubMed  CAS  Google Scholar 

  4. Davis SM, Broderick J, Hennerici M, Brun NC, Diringer MN, Mayer SA, Begtrup K, Steiner T. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology 2006;66(8):1175–81.

    Article  PubMed  CAS  Google Scholar 

  5. Carlberg B, Asplund K, Hagg E. The prognostic value of admission blood pressure in patients with acute stroke. Stroke 1993;24(9):1372–5.

    PubMed  CAS  Google Scholar 

  6. Dandapani BK, Suzuki S, Kelley RE, Reyes-Iglesias Y, Duncan RC. Relation between blood pressure and outcome in intracerebral hemorrhage. Stroke 1995;26(1):21–4.

    PubMed  CAS  Google Scholar 

  7. Fogelholm R, Avikainen S, Murros K. Prognostic value and determinants of first-day mean arterial pressure in spontaneous supratentorial intracerebral hemorrhage. Stroke 1997;28(7):1396–400.

    PubMed  CAS  Google Scholar 

  8. Kazui S, Minematsu K, Yamamoto H, Sawada T, Yamaguchi T. Predisposing factors to enlargement of spontaneous intracerebral hematoma. Stroke 1997;28(12):2370–5.

    PubMed  CAS  Google Scholar 

  9. Ohwaki K, Yano E, Nagashima H, Hirata M, Nakagomi T, Tamura A. Blood pressure management in acute intracerebral hemorrhage: relationship between elevated blood pressure and hematoma enlargement. Stroke 2004;35(6):1364–7.

    Article  PubMed  Google Scholar 

  10. Terayama Y, Tanahashi N, Fukuuchi Y, Gotoh F. Prognostic value of admission blood pressure in patients with intracerebral hemorrhage. Keio Cooperative Stroke Study. Stroke 1997;28(6):1185–8.

    PubMed  CAS  Google Scholar 

  11. Leira R, Davalos A, Silva Y, Gil-Peralta A, Tejada J, Garcia M, Castillo J. Early neurologic deterioration in intracerebral hemorrhage: predictors and associated factors. Neurology 2004;63(3):461–7.

    PubMed  CAS  Google Scholar 

  12. Broderick JP, Diringer MN, Hill MD, Brun NC, Mayer SA, Steiner T, Skolnick BE, Davis SM. Determinants of intracerebral hemorrhage growth: an exploratory analysis. Stroke 2007;38(3):1072–5.

    Article  PubMed  CAS  Google Scholar 

  13. Jauch EC, Lindsell CJ, Adeoye O, Khoury J, Barsan W, Broderick J, Pancioli A, Brott T. Lack of evidence for an association between hemodynamic variables and hematoma growth in spontaneous intracerebral hemorrhage. Stroke 2006;37(8):2061–5.

    Article  PubMed  Google Scholar 

  14. Kidwell CS, Saver JL, Mattiello J, Warach S, Liebeskind DS, Starkman S, Vespa PM, Villablanca JP, Martin NA, Frazee J, Alger JR. Diffusion–perfusion MR evaluation of perihematomal injury in hyperacute intracerebral hemorrhage. Neurology 2001;57(9):1611–7.

    PubMed  CAS  Google Scholar 

  15. Mayer SA, Lignelli A, Fink ME, Kessler DB, Thomas CE, Swarup R, Van Heertum RL. Perilesional blood flow and edema formation in acute intracerebral hemorrhage: a SPECT study. Stroke 1998;29(9):1791–8.

    PubMed  CAS  Google Scholar 

  16. Rosand J, Eskey C, Chang Y, Gonzalez RG, Greenberg SM, Koroshetz WJ. Dynamic single-section CT demonstrates reduced cerebral blood flow in acute intracerebral hemorrhage. Cerebrovasc Dis. 2002;14(3–4):214–20.

    Article  PubMed  Google Scholar 

  17. Qureshi AI, Wilson DA, Hanley DF, Traystman RJ. Pharmacologic reduction of mean arterial pressure does not adversely affect regional cerebral blood flow and intracranial pressure in experimental intracerebral hemorrhage. Crit Care Med. 1999;27(5):965–71.

    Article  PubMed  CAS  Google Scholar 

  18. Qureshi AI, Wilson DA, Hanley DF, Traystman RJ. No evidence for an ischemic penumbra in massive experimental intracerebral hemorrhage. Neurology 1999;52(2):266–72.

    PubMed  CAS  Google Scholar 

  19. Orakcioglu B, Fiebach JB, Steiner T, Kollmar R, Juttler E, Becker K, Schwab S, Heiland S, Meyding-Lamade UK, Schellinger PD. Evolution of early perihemorrhagic changes—ischemia vs. edema: an MRI study in rats. Exp Neurol. 2005;193(2):369–76.

    Article  PubMed  CAS  Google Scholar 

  20. Powers WJ, Zazulia AR, Videen TO, Adams RE, Yundt KD, Aiyagari V, Grubb RL Jr., Diringer, MN. Autoregulation of cerebral blood flow surrounding acute (6 to 22 hours) intracerebral hemorrhage. Neurology 2001;57(1):18–24.

    Article  PubMed  CAS  Google Scholar 

  21. Schellinger PD, Fiebach JB, Hoffmann K, Becker K, Orakcioglu B, Kollmar R, Juttler E, Schramm P, Schwab S, Sartor K, Hacke W. Stroke MRI in intracerebral hemorrhage: is there a perihemorrhagic penumbra? Stroke 2003;34(7):1674–9.

    Article  PubMed  Google Scholar 

  22. Zazulia AR, Diringer MN, Videen TO, Adams RE, Yundt K, Aiyagari V, Grubb RL Jr., Powers WJ. Hypoperfusion without ischemia surrounding acute intracerebral hemorrhage. J Cereb Blood Flow Metab. 2001;21(7):804–10.

    Article  PubMed  CAS  Google Scholar 

  23. Qureshi AI, Mohammad YM, Yahia AM, Suarez JI, Siddiqui AM, Kirmani JF, Suri MF, Kolb J, Zaidat OO. A prospective multicenter study to evaluate the feasibility and safety of aggressive antihypertensive treatment in patients with acute intracerebral hemorrhage. J Intensive Care Med. 2005;20(1):34–42.

    Article  PubMed  Google Scholar 

  24. Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M. Guidelines for the management of spontaneous intracerebral hemorrhage in adults. 2007 Update. A guideline from the American Heart Association, American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38(6):2001–23.

    Article  PubMed  Google Scholar 

  25. Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, Khoury J. The ABCs of measuring intracerebral hemorrhage volumes. Stroke 1996;27(8):1304–5.

    PubMed  CAS  Google Scholar 

  26. Warach S. Editorial comment—is there a perihematomal ischemic penumbra? More questions and an overlooked clue. Stroke 2003;34(7):1680.

    Article  PubMed  Google Scholar 

  27. Qureshi AI, Harris-Lane P, Kirmani JF, Ahmed S, Jacob M, Zada Y, Divani AA. Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association Guidelines. Crit Care Med. 2006;34(7):1975–80.

    Article  PubMed  Google Scholar 

  28. Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, Skolnick BE, Steiner T Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2005;352(8):777–85.

    Article  PubMed  CAS  Google Scholar 

  29. Cheung DG, Gasster JL, Neutel JM, Weber MA. Acute pharmacokinetic and hemodynamic effects of intravenous bolus dosing of nicardipine. Am Heart J. 1990;119(2 Pt 2):438–42.

    Article  PubMed  CAS  Google Scholar 

  30. Qureshi AI. Antihypertensive treatment of acute cerebral hemorrhage (ATACH): rationale and design. Neurocrit Care 2007;6(1):56–66.

    Article  PubMed  CAS  Google Scholar 

  31. Kazui S, Naritomi H, Yamamoto H, Sawada T, Yamaguchi T. Enlargement of spontaneous intracerebral hemorrhage. Incidence and time course. Stroke 1996;27(10):1783–7.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurology, University of Miami Miller School of Medicine, 1150 NW 14th Street, Suite 609, Miami, FL, 33136, USA

    Sebastian Koch, Jose G. Romano, Alejandro M. Forteza, Carolina Mejia Otero & Alejandro A. Rabinstein

Authors
  1. Sebastian Koch
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jose G. Romano
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alejandro M. Forteza
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Carolina Mejia Otero
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Alejandro A. Rabinstein
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sebastian Koch.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Koch, S., Romano, J.G., Forteza, A.M. et al. Rapid Blood Pressure Reduction in Acute Intracerebral Hemorrhage: Feasibility and Safety. Neurocrit Care 8, 316–321 (2008). https://doi.org/10.1007/s12028-008-9085-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-008-9085-8

Keywords

Search

Navigation