Editors' note: Cerebral ischemia and deterioration with lower blood pressure target in intracerebral hemorrhage

ObjectiveTo 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.MethodsWe 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.ResultsOf 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.ConclusionsIntensive 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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Dynamic Cerebral Autoregulation in Acute Intracerebral Hemorrhage

Stroke ◽

10.1161/strokeaha.113.001913 ◽

2013 ◽

Vol 44 (10) ◽

pp. 2722-2728 ◽

Cited By ~ 36

Author(s):

Maximilian Oeinck ◽

Florian Neunhoeffer ◽

Klaus-Juergen Buttler ◽

Stephan Meckel ◽

Bernhard Schmidt ◽

...

Keyword(s):

Blood Pressure ◽

Clinical Outcome ◽

Intracerebral Hemorrhage ◽

Cerebral Autoregulation ◽

Time Course ◽

Low Frequency ◽

Lower Blood Pressure ◽

Clinical Factors ◽

Lower Blood ◽

Acute Intracerebral Hemorrhage

Background and Purpose— Cerebral autoregulation (CA) is not universally impaired in acute intracerebral hemorrhage (ICH); however, the dynamic components of CA are probably more vulnerable. This study, therefore, evaluates the time course of dynamic CA in acute ICH and its relationship to clinical outcome. Methods— Twenty-six patients with ICH were studied on days 1, 3, and 5 after ictus. Dynamic CA was measured from spontaneous fluctuations in blood pressure and middle cerebral artery flow velocity by transfer function phase (reflecting rapidity of CA) and gain (reflecting damping characteristics of CA) in the low frequency range. Results were compared with those from 55 controls and related with clinical factors and 90-day outcome (modified Rankin scale). Results— Phase did not fluctuate significantly over time, nor did it differ between sides or differ from controls. Gain was always higher in patients than in controls but showed no significant association with outcome or other clinical factors. At day 1, poorer ipsilateral phase was associated with lower blood pressure and higher ICH volume. Poorer phase always coincided with lower Glasgow Coma Scale values. Poorer ipsilateral phase on day 5 was related with poorer clinical outcome according to multivariate analysis ( P =0.013). Conclusions— Dynamic temporal characteristics of CA (phase) are not generally altered in acute ICH. Poorer individual phase values are, however, associated with larger ICH volume, lower blood pressure, and worsened outcome. Dampening characteristics of CA (gain) are generally impaired in acute ICH but not related to clinical factors or outcome.

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