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Cerebral ischemia and deterioration with lower blood pressure target in intracerebral hemorrhage
Andrew B Buletko1, Tapan Thacker1, Sung-Min Cho1
1From the Cerebrovascular Center, Neurological Institute (A.B.B., T.T., S.-M.C., J.M., K.U.), Department of Quantitative Health Sciences (N.R.T.), and Neurological Institute Center for Outcomes Research and Evaluation (N.R.T.), Cleveland Clinic, OH; Department of Neurology (N.O.), University of Pennsylvania, Philadelphia; and Department of Neurology (J.A.F.), New York University School of Medicine, New York.
Insights
Intensive lowering of systolic blood pressure (SBP) in acute intracerebral hemorrhage (ICH) patients to below 140 mm Hg, especially below 120 mm Hg, was linked to more cerebral ischemia and neurological decline. This finding suggests caution with aggressive SBP reduction in ICH.
Area of Science:
- Neurology
- Neurosurgery
- Critical Care Medicine
Background:
- Intracerebral hemorrhage (ICH) is a severe condition with high morbidity and mortality.
- Management of blood pressure in acute ICH is critical for patient outcomes.
- Previous guidelines suggested different systolic blood pressure (SBP) targets for ICH management.
Purpose of the Study:
- To evaluate the incidence of acute cerebral ischemia and neurologic deterioration in ICH patients following a change in institutional SBP target.
- To compare outcomes between patients with a target SBP <160 mm Hg versus <140 mm Hg.
Main Methods:
- Retrospective comparison of primary ICH patients admitted before and after an SBP target protocol change.
- Primary outcomes included acute cerebral ischemia on MRI and acute neurologic deterioration.
- 119 patients meeting inclusion criteria were analyzed, divided into SBP target groups (<160 mm Hg or <140 mm Hg).
Main Results:
- The group with a target SBP <140 mm Hg experienced lower mean and minimum SBP compared to the <160 mm Hg group.
- Acute cerebral ischemia was significantly more frequent in the <140 mm Hg group (32% vs 16%).
- Acute neurologic deterioration was also higher in the <140 mm Hg group (19% vs 5%).
- A minimum SBP ≤120 mm Hg was associated with cerebral ischemia; no ischemia occurred with minimum SBP ≥130 mm Hg.
Conclusions:
- Intensive lowering of SBP to <140 mm Hg in acute ICH, particularly allowing SBP <120 mm Hg, is associated with increased remote cerebral ischemic lesions.
- This intensive SBP reduction strategy was also linked to acute neurologic deterioration.
- The findings suggest that very low SBP targets in acute ICH may increase the risk of secondary brain injury.
Objective:
To determine the incidence and predictors of acute cerebral ischemia and neurologic deterioration in intracerebral hemorrhage (ICH) patients after an institutional protocol change in systolic blood pressure (SBP) target from <160 to <140 mm Hg.
Methods:
We retrospectively compared persons admitted with primary ICH before and after a protocol change in SBP target from <160 to <140 mm Hg. The primary outcomes were presence of acute cerebral ischemia on MRI completed within 2 weeks of ICH and acute neurologic deterioration.
Results:
Of 286 persons with primary ICH, 119 underwent MRI and met inclusion criteria. Sixty-two had a target SBP <160 mm Hg (group 1) and 57 had a target SBP <140 mm Hg (group 2). There were no differences between the 2 groups in baseline clinical and radiographic characteristics, but over the first 24 hours of hospitalization, group 2 had lower mean SBP (134 vs 143 mm Hg, p < 0.001) and lower minimum SBP over 72 hours (106 vs 112 mm Hg, p = 0.02). Acute cerebral ischemia was more frequent in group 2 than in group 1 (32% vs 16%; p = 0.047) as was acute neurologic deterioration (19% vs 5%; p = 0.022). A minimum SBP ≤120 mm Hg over 72 hours was associated with cerebral ischemia, while no patient with a minimum SBP ≥130 mm Hg had cerebral ischemia. Acute cerebral ischemia was significantly associated with worse discharge NIH Stroke Scale score, while SBP target was not.
Conclusions:
Intensive lowering of SBP <140 mm Hg in acute ICH, particularly allowing SBP <120 mm Hg, is associated with increased remote cerebral ischemic lesions and acute neurologic deterioration.
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