J-shape relation of blood pressure reduction and outcome in acute intracerebral hemorrhage: A pooled analysis of INTERACT2 and ATACH-II individual participant data

Ultra-Early Blood Pressure Control in Acute Intracerebral Hemorrhage

Acute intracerebral hemorrhage (ICH) remains one of the most devastating neurological emergencies, with blood pressure (BP) management in the early hours playing a pivotal role in determining patient outcomes. Emerging evidence suggests that ultra-early BP control-intervening within minutes to 2 hours of symptom onset-has the potential to reduce secondary brain injury and improve survival. Yet, despite this evidence, current clinical practice is often inconsistent, and there is no universally agreed-upon approach for managing BP in the acute phase of ICH. We advocate for ultra-early BP intervention as a standard of care in ICH, as it offers a clear opportunity to mitigate damage and to enhance recovery. We contend that current BP management protocols are often too conservative and fail to recognize the critical importance of acting swiftly. The first few hours represent a unique window in which targeted interventions, such as continuous infusion intravenous antihypertensives, may limit hematoma expansion and stabilize cerebral perfusion pressure. However, achieving optimal outcomes requires more than just aggressive treatment-it demands a tailored approach to BP control, accounting for individual patient factors, evolving clinical conditions, and operational aspects of care. We advocate for a paradigm shift toward prioritizing ultra-early intervention, supported by clear, evidence-based protocols and real-time decision-making.

Acute Spontaneous Intracerebral Hemorrhage Management Update: Five New Things You Should Know

Intracerebral hemorrhage (ICH) is a devastating condition responsible for millions of global deaths each year. Recent shifts in ICH management highlight a comprehensive care approach focusing on five pivotal components: prediction of hematoma expansion, blood pressure control, hemostasis, anticoagulation reversal, and surgical intervention. Radiological imaging allows clinicians to identify high-risk patients and implement approaches geared toward stabilizing hematoma volume to improve neurological outcomes. Surgical interventions and hematoma evacuation for cerebellar, intraventricular, and supratentorial ICH may also be used to reduce the mass effect from hematomas. This review will highlight the need to integrate all five strategies where appropriate into a bundle of care, with an emphasis on ongoing research in acute ICH management.

Emergency Priorities in the Treatment of Cerebral Hemorrhage: Code-Intracerebral Hemorrhage

The focus of acute treatment of intracerebral hemorrhage (ICH) includes acute blood pressure management, prevention of secondary hematoma expansion through anticoagulation reversal, and neurosurgical interventions for select patients. Recent evidence points to ultra-early acute ICH bundles, implementing multiple therapies in parallel, as the most impactful therapy in reducing morbidity and mortality. It is time for widespread implementation of formalized care bundles in ICH, including specific metrics for time to treatment and criteria for neurosurgical therapy. No longer just "Code Stroke," it is time for "Code ICH.".

Individualized autoregulation-guided arterial blood pressure management in neurocritical care

Cerebral autoregulation (CA) is the physiological process by which cerebral blood flow is maintained during fluctuations in arterial blood pressure (ABP). There are various validated methods to measure CA, either invasively, with intracranial pressure or brain tissue oxygenation monitors, or noninvasively, with transcranial Doppler ultrasound or near-infrared spectroscopy. Utilizing these monitors, researchers have been able to discern CA patterns in several pathological states, such as but not limited to acute ischemic stroke, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, sepsis, and post-cardiac arrest, and they have found CA to be altered in these patients. CA disturbances predispose patients suffering from these ailments to worse outcomes. Much focus has been placed on CA monitoring in these populations, with an emphasis on arterial blood pressure optimization. Many guidelines recommend universal static ABP targets; however, in patients with altered CA, these targets may make them susceptible to hypoperfusion and further neurological injury. Based on this observation, there has been much investigation on individualized ABP goals and their effect on clinical outcomes. The scope of this review includes (1) a summary of the physiology of CA in healthy adults; (2) a review of the evidence on CA monitoring in healthy individuals; (3) a summary of CA changes and its effect on outcomes in various diseased states including acute ischemic stroke, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, sepsis and meningitis, post-cardiac arrest, hypoxic-ischemic encephalopathy, surgery, and moyamoya disease; and (4) a review of the current evidence on individualized ABP changes in various patient populations.

Effects of Mobile Stroke Unit dispatch on blood pressure management and outcomes in patients with intracerebral haematoma: Results from the Berlin_Prehospital Or Usual Care Delivery in acute Stroke (B_PROUD) controlled intervention study

INTRODUCTION

In patients with acute intracerebral haemorrhage (ICH) and elevated systolic blood pressure (BP), guidelines suggest that systolic BP reduction to <140 mmHg should be rapidly initiated. Compared with conventional care, Mobile Stroke Units (MSUs) allow for earlier ICH diagnosis through prehospital imaging and earlier BP lowering.

PATIENTS AND METHODS

ICH patients were prospectively evaluated as a cohort of the controlled B_PROUD-study in which MSU availability alone determined MSU dispatch in addition to conventional ambulance. We used inverse probability of treatment weighting to adjust for confounding to estimate the effect of additional MSU dispatch in ICH patients. Outcomes of interest were 7-day mortality (primary), systolic BP (sBP) at hospital arrival, dispatch-to-imaging time, largest haematoma volume, anticoagulation reversal, length of in-hospital stay, 3-month functional outcome.

RESULTS

Between February 2017 and May 2019, MSUs were dispatched to 95 (mean age: 72 ± 13 years, 45% female) and only conventional ambulances to 78 ICH patients (mean age: 71 ± 12 years, 44% female). After adjusting for confounding, we found shorter dispatch-to-imaging time (mean difference: -17.75 min, 95% CI: -27.16 to -8.21 min) and lower sBP at hospital arrival (mean difference = -16.31 mmHg, 95% CI: -30.64 to -6.19 mmHg) in the MSU group. We found no statistically significant difference for the other outcomes, including 7-day mortality (adjusted odds ratio: 1.43, 95% CI: 0.68 to 3.31) or favourable outcome (adjusted odds ratio = 0.67, 95% CI: 0.27 to 1.67).

CONCLUSIONS

Although MSU dispatch led to sBP reduction and lower dispatch-to-imaging time compared to conventional ambulance care, we found no evidence of better outcomes in the MSU dispatch group.

Intensive Ambulance-Delivered Blood-Pressure Reduction in Hyperacute Stroke

BACKGROUND

Treatment of acute stroke, before a distinction can be made between ischemic and hemorrhagic types, is challenging. Whether very early blood-pressure control in the ambulance improves outcomes among patients with undifferentiated acute stroke is uncertain.

METHODS

We randomly assigned patients with suspected acute stroke that caused a motor deficit and with elevated systolic blood pressure (≥150 mm Hg), who were assessed in the ambulance within 2 hours after the onset of symptoms, to receive immediate treatment to lower the systolic blood pressure (target range, 130 to 140 mm Hg) (intervention group) or usual blood-pressure management (usual-care group). The primary efficacy outcome was functional status as assessed by the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days after randomization. The primary safety outcome was any serious adverse event.

RESULTS

A total of 2404 patients (mean age, 70 years) in China underwent randomization and provided consent for the trial: 1205 in the intervention group and 1199 in the usual-care group. The median time between symptom onset and randomization was 61 minutes (interquartile range, 41 to 93), and the mean blood pressure at randomization was 178/98 mm Hg. Stroke was subsequently confirmed by imaging in 2240 patients, of whom 1041 (46.5%) had a hemorrhagic stroke. At the time of patients' arrival at the hospital, the mean systolic blood pressure in the intervention group was 159 mm Hg, as compared with 170 mm Hg in the usual-care group. Overall, there was no difference in functional outcome between the two groups (common odds ratio, 1.00; 95% confidence interval [CI], 0.87 to 1.15), and the incidence of serious adverse events was similar in the two groups. Prehospital reduction of blood pressure was associated with a decrease in the odds of a poor functional outcome among patients with hemorrhagic stroke (common odds ratio, 0.75; 95% CI, 0.60 to 0.92) but an increase among patients with cerebral ischemia (common odds ratio, 1.30; 95% CI, 1.06 to 1.60).

CONCLUSIONS

In this trial, prehospital blood-pressure reduction did not improve functional outcomes in a cohort of patients with undifferentiated acute stroke, of whom 46.5% subsequently received a diagnosis of hemorrhagic stroke. (Funded by the National Health and Medical Research Council of Australia and others; INTERACT4 ClinicalTrials.gov number, NCT03790800; Chinese Trial Registry number, ChiCTR1900020534.).

Hypertensive crisis: diagnosis, presentation, and treatment

PURPOSE OF REVIEW

Hypertensive crisis (HTN-C) is a condition of increasing prevalence. It carries significant morbidity and mortality, and prompt recognition and treatment are crucial. There is a paucity of controlled trials, so a working knowledge of the most recent literature in the area of HTN-C is helpful.

RECENT FINDINGS

Novel serological markers, including serum corin, have been found to aid in the early identification of end-organ damage from severely elevated blood pressure (BP). In the area of BP following thrombolysis for ischemic stroke, lower target BP (130-140 mmHg) is associated with some improved outcomes. Two large trials of lower BP following mechanical thrombectomy in stroke have failed to show improved outcomes; however, observed data show benefits at lower than currently recommended levels. Clevidipine, a calcium channel blocker marketed for unique use in HTN-C, was found to be noninferior to the generic less expensive nicardipine. Oral nifedipine was found to be the most effective agent for sustained BP reduction in preeclampsia.

SUMMARY

HTN-C remains an area with few prospective randomized trials, but there is active research on identifying lower goals for specific clinical scenarios. Ideal therapeutic agents should be tailored for specific end-organ damage.

Intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is a dramatic condition caused by the rupture of a cerebral vessel and the entry of blood into the brain parenchyma. ICH is a major contributor to stroke-related mortality and dependency: only half of patients survive for 1 year after ICH, and patients who survive have sequelae that affect their quality of life. The incidence of ICH has increased in the past few decades with shifts in the underlying vessel disease over time as vascular prevention has improved and use of antithrombotic agents has increased. The pathophysiology of ICH is complex and encompasses mechanical mass effect, haematoma expansion and secondary injury. Identifying the causes of ICH and predicting the vital and functional outcome of patients and their long-term vascular risk have improved in the past decade; however, no specific treatment is available for ICH. ICH remains a medical emergency, with prevention of haematoma expansion as the key therapeutic target. After discharge, secondary prevention and management of vascular risk factors in patients remains challenging and is based on an individual benefit-risk balance evaluation.

Early blood pressure management in hemorrhagic stroke: a meta-analysis

The aim of the present meta-analysis was to evaluate the outcomes and effects of different systolic blood pressure (SBP) lowering in patients with hemorrhagic stroke using data from randomized controlled trials. A total of 2592 records were identified for this meta-analysis. We finally included 8 studies (6119 patients; mean age 62.8 ± 13.0, 62.7% men). No evidence of heterogeneity between estimates (I² = 0% < 50%, P = 0.26), or publication bias in the funnel plots (P = 0.065, Egger statistical test) was detected. Death or major disability rates were similar between patients with intensive BP-lowering treatment (SBP < 140 mmHg) and those receiving guideline BP-lowering treatment (SBP < 180 mmHg). Intensive BP-lowering treatment may have a better functional outcome, but the results were not significantly different (log RR = - 0.03, 95% CI: - 0.09 to 0.02; P = 0.55). Intensive BP-lowering treatment tended to be associated with lower early hematoma growth compared with guideline treatment (log RR = - 0.24, 95% CI - 0.38, - 0.11; P < 0.001). Intensive BP-lowering helps reduce hematoma enlargement in the early stage of acute hemorrhagic stroke. However, this observation did not translate into functional outcomes. Further research is needed to clarify the specific scope and time of blood pressure reduction.

Bringing High-Dose Neurorestorative Behavioral Training Into the Acute Stroke Unit

ABSTRACT

Stroke remains common and is a leading cause of adult disability. While there have been enormous system changes for the diagnosis and delivery of hyperacute stroke treatments at comprehensive stroke centers, few advances have been made in those same centers for treatments focused on behavioral recovery and brain repair. Specifically, during the early hospital period, there is a paucity of approaches available for reduction of impairment beyond what is expected from spontaneous biological recovery. Thus, patients in the early stroke recovery period are not receiving the kind of training needed, at the requisite intensity and dose, to exploit a potential critical period of heightened brain plasticity that could maximize true recovery instead of just compensation. Here, we describe an ongoing pilot program to reconfigure the acute stroke unit experience to allow for a new emphasis on brain repair. More specifically, we have introduced a novel room-based video-gaming intervention; restorative neuroanimation, into the acute stroke hospital setting. This new intervention provides the opportunity for an extra hour(s) of high-intensity neurorestorative behavioral treatment that is complementary to conventional rehabilitation. To accomplish this, system redesign was required to insert this new treatment into the patient day, to properly stratify patients behaviorally and physiologically for the treatment, to optimize the digital therapeutic approach itself, and to maintain the impairment reduction after discharge.

Predictive Nomogram for Unfavorable Outcome of Spontaneous Intracerebral Hemorrhage

BACKGROUND

The goal of this retrospective study was to evaluate the effect of surgical timing on patient outcomes after spontaneous intracerebral hemorrhage (ICH). We also identified risk factors associated with poor prognosis.

METHODS

We reviewed all patients who underwent surgery for ICH between January 2014 and January 2021. The outcome was measured using the modified Rankin Scale (mRS) score at 6 months after the surgery. Patients with mRS 0-2 were considered having favorable outcomes, and those with mRS 3-5 were considered having unfavorable outcomes. The relationships of surgical timing with the risk of unfavorable outcomes were identified using the interaction and stratified analyses, and generalized additive and logistic regression models. A nomogram was established and evaluated using a receiver operating characteristic curve analysis, plotted decision curve, and calibration curve.

RESULTS

We identified 53 patients with favorable outcomes and 144 with unfavorable outcomes. The number of cases who underwent surgery at >12 hours and <36 hours in the favorable outcome group was more than that in the unfavorable outcome group (P < 0.001). When the time to operating room (TOR) was less than 21 hours, a shorter TOR was associated with unfavorable outcomes, using the smoothing spline analysis (odds ratio = 0.8, P < 0.001). Finally, we developed a nomogram using systolic blood pressure, Glasgow Coma Scale, midline shift, hematoma volume, and TOR for predicting the unfavorable outcome. The area under the curve, accuracy, specificity, and sensitivity of nomogram were 0.90, 0.87, 0.72, and 0.93, respectively.

CONCLUSION

Surgical timing between 12 and 26 hours after ICH was associated with favorable outcomes. The nomogram including systolic blood pressure, Glasgow Coma Scale, midline shift, hematoma volume, and TOR was reliable for predicting the ICH outcome.