Ultra‐Early Blood Pressure Reduction Attenuates Hematoma Growth and Improves Outcome in Intracerebral Hemorrhage

Abstract

Objective The aim was to investigate whether intensive blood pressure treatment is associated with less hematoma growth and better outcome in intracerebral hemorrhage (ICH) patients who received intravenous nicardipine treatment ≤2 hours after onset of symptoms. Methods A post‐hoc exploratory analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH‐2) trial was performed. This was a multicenter, international, open‐label, randomized clinical trial, in which patients with primary ICH were allocated to intensive versus standard blood pressure treatment with nicardipine ≤4.5 hours after onset of symptoms. We have included 913 patients with complete imaging and follow‐up data in the present analysis. Results Among the 913 included patients, 354 (38.7%) had intravenous nicardipine treatment initiated within 2 hours. In this subgroup of patients treated within 2 hours, the frequency of ICH expansion was significantly lower in the intensive blood pressure reduction group compared with the standard treatment group (p = 0.02). Multivariable analysis showed that ultra‐early intensive blood pressure treatment was associated with a decreased risk of hematoma growth (odds ratio, 0.56; 95% confidence interval [CI], 0.34–0.92; p = 0.02), higher rate of functional independence (odds ratio, 2.17; 95% CI, 1.28–3.68; p = 0.004), and good outcome (odds ratio, 1.68; 95% CI, 1.01–2.83; p = 0.048) at 90 days. Ultra‐early intensive blood pressure reduction was associated with a favorable shift in modified Rankin Scale score distribution at 3 months (p = 0.04). Interpretation In a subgroup of ICH patients with elevated blood pressure given intravenous nicardipine ≤2 hours after onset of symptoms, intensive blood pressure reduction was associated with reduced hematoma growth and improved functional outcome. ANN NEUROL 2020;88:388–395.

Admission Dehydration Is Associated With Significantly Lower In-Hospital Mortality After Intracerebral Hemorrhage

“…The mechanisms of the effect are unclear. There are a few possibilities: (1) dehydration is known to increase blood viscosity and to decrease blood pressure and cerebral perfusion (4,15), leading to reduced hematoma growth and good in-hospital outcome (16,17). (2) Dehydration-related hypovolemia and hypernatremia may increase intravascular osmolality and reduce perihematomal edema and intracranial pressure (18)(19)(20)(21)(22).…”

New Prediction Models of Functional Outcome in Acute Intracerebral Hemorrhage: The dICH Score and uICH Score

“…Notably, many ICH patients arrive at the emergency department within several hours due to the rapid symptom onset. In addition, a recent secondary analysis of the ATACH2 trial results suggested that ultra-early blood pressure reduction was associated with a reduced rate of hematoma growth and improved functional outcomes in ICH patients ( 33 ). Therefore, outcome prediction within a few hours after ICH onset is important for clinicians to delineate the potential benefits of aggressive care.…”

Advances in pre-hospital care - operational experiences from the Melbourne mobile stroke unit

“…Using a comparator of all direct and metropolitan secondary transfer patients to the largest EVT center in Victoria (Royal Melbourne Hospital), patients receiving facilitated thrombectomy via the Melbourne MSU did so a median of 51 min (95%CI: 30-72) faster. On further analysis, cases that bypassed of the local non-EVT hospital received the most time saving of 71 min (95%CI: 46-96), whereas the equivalent time saving if the patient was located closest to a comprehensive center was 6 min (95%CI: [19][20][21][22][23][24][25][26][27][28][29][30][31]. This suggests that a large proportion of the time savings are due to improved triage and avoidance of secondary transfers.…”

“…Although effective treatments are much more limited for parenchymal intracerebral hemorrhage, a posthoc analysis of a major trial of aggressive blood pressure management in intracerebral hemorrhage demonstrated improved outcomes if anti-hypertensive therapy is initiated within 2 h of symptom onset [31] . In the first 365 days, 42% of MSU hemorrhage patients required acute intravenous anti-hypertensive therapy, which would be delayed if patients received standard ambulance transport.…”