Association between 24-h blood pressure monitoring variables and brain oedema in patients with hyperacute stroke

Jusufovic

et al. 2015

Stroke

Background and Purpose— The Scandinavian Candesartan Acute Stroke Trial (SCAST) found no benefits of blood pressure–lowering treatment with candesartan in acute stroke. We have investigated whether the effect of treatment is different in different subtypes of ischemic stroke. Methods— SCAST was a randomized- and placebo-controlled trial of candesartan in 2029 patients presenting within 30 hours of ischemic or hemorrhagic stroke and systolic blood pressure ≥140 mm Hg. Ischemic stroke subtype was categorized by the Oxfordshire Community Stroke Project classification. There were 2 primary effect variables: the composite vascular end point of vascular death, myocardial infarction, or stroke during the first 6 months and functional outcome at 6 months. Results— A total of 1733 patients with ischemic stroke were included: total anterior circulation infarcts in 129, partial anterior in 850, posterior in 236, and lacunar in 510 patients. For functional outcome there was a significant trend toward a better effect of candesartan in patients with larger infarcts (total anterior circulation or partial anterior circulation) than in patients with smaller infarcts (lacunar infarction; P =0.02). For the composite vascular end point, there were no differences in treatment effect. Conclusions— The results suggest that the effect of blood pressure–lowering treatment with candesartan may differ according to different types of acute ischemic stroke, but this needs to be confirmed in future trials. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00120003.

Section: Discussionmentioning

confidence: 99%

Effects of Blood Pressure–Lowering Treatment in Different Subtypes of Acute Ischemic Stroke

Jusufovic

et al. 2015

Stroke

“…5 Perihematomal edema formation may be a potential mechanism to connect high BP levels during the later hours with poor outcomes. 11 Another potential explanation for our results might be that 11% of our study patients were taking antithrombotic medications, and active bleeding in these patients might be prolonged. Therefore, a longer duration of AHT might be warranted.…”

Section: Discussionmentioning

confidence: 90%

Continuous Antihypertensive Therapy Throughout the Initial 24 Hours of Intracerebral Hemorrhage

Kobayashi

Koga

Tanaka

et al. 2014

Stroke

Background and Purpose— A short duration (<24 hours) of antihypertensive therapy (AHT) after acute intracerebral hemorrhage (ICH) may be sufficient because active bleeding generally ceases within several hours. We aimed to determine the association between sequential systolic blood pressure (SBP) levels during AHT and outcomes in ICH patients. Methods— In 211 hyperacute ICH patients who underwent AHT based on predefined protocol, the mean of hourly SBP (mSBP) measurements was calculated over 1 to 8 hours (first mSBP), 9 to 16 hours (second mSBP), and 17 to 24 hours (third mSBP) after the initiation of AHT. Outcomes included neurological deterioration (72-hour Glasgow Coma Scale decrease ≥2 or National Instititutes of Health Stroke Scale increase ≥4), hematoma expansion (>33%), and unfavorable outcome (3-month modified Rankin Scale score 4–6). Results— The median first, second, and third mSBPs were 132, 131, and 137 mm Hg, respectively. A higher first mSBP (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.34–4.69 per 10 mm Hg) or second mSBP (OR, 2.08; 95% CI, 1.20–3.80) was independently associated with neurological deterioration, and a higher second mSBP (OR, 1.40; 95% CI, 1.02–2.00) or third mSBP (OR, 1.45; 95% CI, 1.05–2.05) was associated with unfavorable outcome. None of the mSBPs was associated with hematoma expansion. Conclusions— The continuation of AHT throughout the initial 24 hours after ICH may improve outcomes.

“…Modern neuro-imaging studies indicate that continued bleeding and expansion of the hematoma occurs in up to one third of patients within the first several hours of onset, and probably over three to twenty-four hours in another ten percent [3] [4]. Further neurological deterioration may occur over several days secondary to the adverse effects of edema and inflammation in the peri-hematomal region [5]. Most cases of ICH are attributed to chronic hypertension and the vast majority of these patients are severely hypertensive in the first twenty-four hours of their stroke.…”

Section: Discussionmentioning

confidence: 99%

“…Early hematoma growth occurs in the absence of a measurable coagulopathy and appears to result from continued bleeding or re-bleeding at multiple sites within the first few hours after onset. Early hematoma growth may be exacerbated by arterial hypertension and by local coagulopathy induced by the hematoma [1]- [5].…”

Section: Discussionmentioning

confidence: 99%

“…ICH affects greater than 1 million people a year and the majority of patients suffer significant disability or death [1] [2]. An initially high systolic blood pressure upon presentation is associated with hematoma expansion [3] [4], peri-hematoma expansion [5], and increased mortality [6]. The relationship between blood pressure, the degree of blood pressure control and hematoma expansion has yet to be defined, but the literature has observed a relationship between tightly controlled blood pressures and decreased hematoma expansion [7]- [9].…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Aggressive Blood Pressure Control in Intracerebral Hemorrhage (the Abc-Ich Study)—A Pilot Study

Sloas¹,

Malkani²,

Shangha³

et al. 2014

OJEM

Spontaneous intracerebral hemorrhage (ICH) accounts for one fifth of all strokes and is associated with an extremely high rate of morbidity and mortality. Affecting greater than 1 million people a year, ICH will leave the majority of its' patients significantly disabled or dead. An initially high systolic blood pressure upon presentation is associated with hematoma expansion, peri-hematoma expansion, and increased mortality. The relationship between blood pressure, the degree of blood pressure control and hematoma expansion has yet to be defined, but the literature has observed a relationship between tightly controlled blood pressures and decreased hematoma expansion. There have been many proposed mechanisms to explain this effect. Larger initial hematomas may lend greater hydrostatic forces and this could result in greater total hematoma volume, and greater surrounding edema. Recent literature has suggested that blood pressure reductions in acute ICH may be tolerated because of reduced metabolism, and preserved autoreguation in the peri-hematoma region. The volume of the hematoma is a critical determinant of mortality and functional outcome after intracerebral hemorrhage, and early hematoma growth is an important cause of neurologic deterioration. An increase in volume of more than thirty-three percent is detectable on repeated computed tomography (CT) in thirty-eight percent of patients initially scanned within the first three hours of onset of symptoms; in two thirds of these cases this change is noticeable on CT within the first hour. This supports the hypothesis that early aggressive blood pressure optimization would decrease hematoma size and edema. This is further supported by the fact that patients with high blood pressure and acute intracerebral hemorrhage have worse outcomes than their counterparts. We hypothesize that prompt and aggressive, early blood pressure reduction in emergency department patients with acute spontaneous intracerebral hemorrhage will result in a reduction of early hematoma growth. The study institution is a large urban emer- H. A. Sloas et al. 20gency department and tertiary care stoke center, with over 55,000 emergency department visits per year. This prospective cohort study compared the results and outcomes observed within the enrolled prospective study population, to the results and outcomes of a matched historical cohort population (future patients with intracranial hemorrhage that did not receive the ABC-ICH protocol). Methods and Material: A nicardipine infusion was administered to optimize blood pressure in all patients presenting with intracerebral hemorrhage with a target mean arterial pressure (MAP) of 80 -110. Hematoma volume (primary outcome measure) was measured on cat scans at time of presentation and at twenty-four hours. The hematoma volume in the enrolled prospective study population was compared to those of a matched cohort (patients with intracranial hemorrhage that did not receive the ABC-ICH protocol following the conclusion of the study). Results: O...