Relationship Between Changes in Prehospital Blood Pressure and Early Neurological Deterioration in Spontaneous Intracerebral Hemorrhage

Abstract Background Intracerebral hemorrhage (ICH) is caused by bleeding, primarily into parenchymal brain tissue, and accounts for 9 to 27% of all strokes worldwide. Higher neutrophils, lower lymphocytes, and higher neutrophil-to-lymphocytes ratio (NLR) values predict worse outcomes after spontaneous intracranial hemorrhage (sICH) and could aid in the risk stratification of patients. Methods Eighty patients with sICH within the first 24 h of stroke onset and admitted into the neurology intensive care unit of an Egyptian university hospital and were assessed by GCS for consciousness level and NIHSS for stroke severity assessment, complete blood count, and special attention to NLR. Patients were reevaluated by GCS and NIHSS on the 7th day of the stroke. Early neurological deterioration (END) was defined as four points or a greater increase in the NIHSS score or two points or a greater decrease in GCS or death. Results END was recorded in 21.25% of patients while non-END was recorded in 78.75%. END was highly significantly associated with a low grade of GCS, high grade of NIHSS, elevated absolute lymphocyte count (ALC), and elevated NLR. Lower GCS score, higher NIHSS score, larger hematoma volume, and higher NLR values were independent predictors for END. The best cutoff of NLR in END prediction was > 9.1. Conclusion NLR is a trustworthy early predictor of sICH outcome.

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Late Neurological Deterioration after Acute Intracerebral Hemorrhage: A post hoc Analysis of the ATACH-2 Trial

Cerebrovascular Diseases ◽

10.1159/000506117 ◽

2020 ◽

Vol 49 (1) ◽

pp. 26-31 ◽

Cited By ~ 1

Author(s):

Shuhei Okazaki ◽

Haruko Yamamoto ◽

Lydia D. Foster ◽

Mayumi Fukuda-Doi ◽

Masatoshi Koga ◽

...

Keyword(s):

Blood Pressure ◽

Intracerebral Hemorrhage ◽

Significant Risk ◽

Blood Pressure Level ◽

Neurological Deterioration ◽

Major Influence ◽

Case Report Form ◽

Hematoma Volume ◽

Systolic Blood Pressure Level ◽

Significant Difference

Background: Neurological deterioration (ND) has a major influence on the prognosis of intracerebral hemorrhage (ICH); however, factors associated with ND occurring after 24 h of ICH onset are unknown. Methods: We performed exploratory analyses of data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial, which compared intensive and standard blood pressure lowering treatment in ICH. NDs were captured on the adverse event case report form. Logistic regression analysis was performed to examine the independent predictors of late ND. Results: Among 1,000 participants with acute ICH, 82 patients (8.2%) developed early ND (≤24 h), and 64 (6.4%) had late ND. Baseline hematoma volume (adjusted OR [aOR] per 1-cm3 increase 1.04, 95% CI 1.02–1.06, p < 0.0001), hematoma volume increase in 24 h (aOR 2.24, 95% CI 1.23–4.07, p = 0.008), and the presence of intraventricular hemorrhage (IVH; aOR 2.38, 95% CI 1.32–4.29, p = 0.004) were independent predictors of late ND (vs. no late ND). Late ND was a significant risk factor for poor 90-day outcome (OR 3.46, 95% CI 1.82–6.56). No statistically significant difference in the incidence of late ND was noted between the 2 treatment groups. Conclusions: Initial hematoma volume, early hematoma volume expansion, and IVH are independent predictors of late ND after ICH. Intensive reduction in the systolic blood pressure level does not prevent the development of late ND.

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Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis

Neurology ◽

10.1212/wnl.0000000000013049 ◽

2021 ◽

pp. 10.1212/WNL.0000000000013049

Author(s):

Aristeidis H Katsanos ◽

Konark Malhotra ◽

Niaz Ahmed ◽

Georgios Seitidis ◽

Eva A. Mistry ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Individual Patient Data ◽

Patient Data ◽

Neurological Deterioration ◽

Endovascular Thrombectomy ◽

Early Neurological Deterioration ◽

Symptomatic Intracranial Hemorrhage

Objective:To explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO).Methods:A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model.Results:A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission: 16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT.Conclusion:Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.

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Abstract W MP12: Changing Policies for Blood Pressure Management in Spontaneous Intracerebral Hemorrhage

Stroke ◽

10.1161/str.45.suppl_1.wmp12 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Jill Slater ◽

Holly Morhaim ◽

Steven Rudolph

Keyword(s):

Blood Pressure ◽

Intracerebral Hemorrhage ◽

Heart Association ◽

Teaching Hospitals ◽

Spontaneous Intracerebral Hemorrhage ◽

Pressure Management ◽

Practice Nurses ◽

Program Coordinators ◽

Blood Pressure Management ◽

Stroke Center

Background: Current American Heart Association guidelines for targeted blood pressure management in spontaneous intracerebral hemorrhage (ICH), published in 2010, suggest a target mean arterial pressure of less than 110 or a blood pressure of less than 160/90 in patients without elevated intracranial pressure. These guidelines acknowledge that these recommendations have been based on incomplete efficacy evidence. A lower level recommendation was given for reducing target blood pressure to a systolic of 140, based on the INTERACT trial published in 2008. The INTERACT2 trial, published in May 2013, has been interpreted to establish the safety of rapid blood pressure lowering to 140 systolic. Purpose: To determine the current level of adoption by stroke centers of lower targets for blood pressure in patients with spontaneous intracerebral hemorrhage, and whether these targets have changed in 2013. Methods: We developed a web-based survey that was distributed via email and professional groups to stroke advanced practice nurses and stroke program coordinators. The survey asked specific questions regarding changes in clinical practice and stroke center policies on blood pressure management in spontaneous ICH. The survey was anonymous, and the survey software was able to exclude multiple entries from the same computer. Results: Responses were obtained from academic medical centers, community teaching hospitals, and community non-teaching hospitals. Awareness of the results of INTERACT2 was known by 65%, 50%, and 31% of stroke nurses at these hospitals, respectively. Targets for systolic blood pressure were changed in 2013 at 46%, 44%, and 11% of hospitals by group. A time target to lower blood pressure of less than one hour was adopted by 57%, 46%, and 28% respectively. Conclusion: Stroke centers have rapidly adopted changes in blood pressure management in intracerebral hemorrhage in advance of guideline revisions. Non-teaching hospitals were less likely to adopt these changes.

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Predictors and Outcomes of Neurological Deterioration in Intracerebral Hemorrhage: Results from the TICH-2 Randomized Controlled Trial

Translational Stroke Research ◽

10.1007/s12975-020-00845-6 ◽

2020 ◽

Author(s):

Zhe Kang Law ◽

◽

Rob Dineen ◽

Timothy J England ◽

Lesley Cala ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Intracerebral Hemorrhage ◽

Tranexamic Acid ◽

Controlled Trial ◽

Neurological Deterioration ◽

Unique Identifier ◽

Risk Of Death ◽

Randomized Controlled ◽

Early Neurological Deterioration ◽

The Uk

Abstract Neurological deterioration is common after intracerebral hemorrhage (ICH). We aimed to identify the predictors and effects of neurological deterioration and whether tranexamic acid reduced the risk of neurological deterioration. Data from the Tranexamic acid in IntraCerebral Hemorrhage-2 (TICH-2) randomized controlled trial were analyzed. Neurological deterioration was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) of ≥ 4 or a decline in Glasgow Coma Scale of ≥ 2. Neurological deterioration was considered to be early if it started ≤ 48 h and late if commenced between 48 h and 7 days after onset. Logistic regression was used to identify predictors and effects of neurological deterioration and the effect of tranexamic acid on neurological deterioration. Of 2325 patients, 735 (31.7%) had neurological deterioration: 590 (80.3%) occurred early and 145 (19.7%) late. Predictors of early neurological deterioration included recruitment from the UK, previous ICH, higher admission systolic blood pressure, higher NIHSS, shorter onset-to-CT time, larger baseline hematoma, intraventricular hemorrhage, subarachnoid extension and antiplatelet therapy. Older age, male sex, higher NIHSS, previous ICH and larger baseline hematoma predicted late neurological deterioration. Neurological deterioration was independently associated with a modified Rankin Scale of > 3 (aOR 4.98, 3.70–6.70; p < 0.001). Tranexamic acid reduced the risk of early (aOR 0.79, 0.63–0.99; p = 0.041) but not late neurological deterioration (aOR 0.76, 0.52–1.11; p = 0.15). Larger hematoma size, intraventricular and subarachnoid extension increased the risk of neurological deterioration. Neurological deterioration increased the risk of death and dependency at day 90. Tranexamic acid reduced the risk of early neurological deterioration and warrants further investigation in ICH. URL:https://www.isrctn.com Unique identifier: ISRCTN93732214

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