The intracerebral hemorrhage acutely decreasing arterial pressure trial II (ICH ADAPT II) protocol

Intracerebral haemorrhage expansion: definitions, predictors, and prevention

Haematoma expansion affects a fifth of patients within 24 h of the onset of acute intracerebral haemorrhage and is associated with death and disability, which makes it an appealing therapeutic target. The time in which active intervention can be done is short as expansion occurs mostly within the first 3 h after onset. Baseline haemorrhage volume, antithrombotic treatment, and CT angiography spot signs are each associated with increased risk of haematoma expansion. Non-contrast CT features are promising predictors of haematoma expansion, but their potential contribution to current models is under investigation. Blood pressure lowering and haemostatic treatment minimise haematoma expansion but have not led to improved functional outcomes in randomised clinical trials. Ultra-early enrolment and selection of participants on the basis of non-contrast CT imaging markers could focus future clinical trials to show clinical benefit in people at high risk of expansion or investigate heterogeneity of treatment effects in clinical trials with broad inclusion criteria.

Changes in Cerebral Blood Flow and Diffusion-Weighted Imaging Lesions After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a common subtype of stroke and places a great burden on the family and society with a high mortality and disability rate and a poor prognosis. Many findings from imaging and pathologic studies have suggested that cerebral ischemic lesions visualized on diffusion-weighted imaging (DWI) in patients with ICH are not rare and are generally considered to be associated with poor outcome, increased risk of recurrent (ischemic and hemorrhagic) stroke, cognitive impairment, and death. In this review, we describe the changes in cerebral blood flow (CBF) and DWI lesions after ICH and discuss the risk factors and possible mechanisms related to the occurrence of DWI lesions, such as cerebral microangiopathy, cerebral atherosclerosis, aggressive early blood pressure lowering, hyperglycemia, and inflammatory response. We also point out that a better understanding of cerebral DWI lesions will be a key step toward potential therapeutic interventions to improve long-term recovery for patients with ICH.

Remote diffusion-weighted imaging lesions and blood pressure variability in primary intracerebral hemorrhage

Objective

The aim of this study was to examine the association between remote diffusion-weighted imaging lesions (R-DWILs) and blood pressure variability (BPV) in patients with primary intracerebral hemorrhage (ICH).

Methods

We conducted a retrospective review of a consecutive cohort of 375 patients with primary ICH within 24 h onset. R-DWILs were defined as hyperintensity lesions in DWI remote from the hematoma. Blood pressure recordings were extracted up to 24 h post-admission. BPV was measured using SD, coefficient of variation (CV), and successive variation (SV).

Results

Remote DWI lesions were detected in 65 (17.3%) primary ICH patients. In multivariable logistic regression analysis, parameters of BPV were independently associated with R-DWILs, and the results remained consistent after being adjusted with mean SBP. SD, CV, and SV values in the highest quintile, showed 3- to 8-fold increased risk of R-DWILs, compared with the lowest quintile. ΔSBP demonstrated a significant difference in 2 different predictive models. Max SBP only dictated a significant difference in model 1. Mean SBP, admission SBP, and min SBP, failed to present an association with R-DWILs in model 1 or model 2.

Conclusion

Our results provided additional evidence that BPV is associated with the development of R-DWILs in primary ICH.

Acute Hypertensive Response in Patients With Acute Intracerebral Hemorrhage: A Narrative Review

OBJECTIVE

To review the role of the acute hypertensive response in patients with intracerebral hemorrhage, current treatment options, and areas for further research.

METHODS

Review of the literature to assess 1) frequency of acute hypertensive response in intracerebral hemorrhage; 2) consequences of acute hypertensive response in clinical outcomes; 3) acute hypertensive response and secondary brain injury: hematoma expansion and perihematomal edema; 4) vascular autoregulation, safety data side effects of acute antihypertensive treatment; and 5) randomized clinical trials and meta-analyses.

RESULTS

An acute hypertensive response is frequent in patients with acute intracerebral hemorrhage and is associated with poor clinical outcomes. However, it is not clear whether high blood pressure is a cause of poor clinical outcome or solely represents a marker of severity. Although current guidelines recommend intensive blood pressure treatment (<140 mm Hg) in patients with intracerebral hemorrhage, 2 randomized clinical trials have failed to demonstrate a consistent clinical benefit from this approach, and new data suggest that intensive blood pressure treatment could be beneficial for some patients but detrimental for others.

CONCLUSIONS

Intracerebral hemorrhage is a heterogenous disease, thus, a one-fit-all approach for blood pressure treatment may be suboptimal. Further research should concentrate on finding subgroups of patients more likely to benefit from aggressive blood pressure lowering, considering intracerebral hemorrhage etiology, ultra-early randomization, and risk markers of hematoma expansion on brain imaging.

Lower Blood Pressure Is Not Associated With Decreased Arterial Spin Labeling Estimates of Perfusion in Intracerebral Hemorrhage

Background

Subacute ischemic lesions in intracerebral hemorrhage (ICH) have been hypothesized to result from hypoperfusion. Although studies of cerebral blood flow (CBF) indicate modest hypoperfusion in ICH, these investigations have been limited to early time points. Arterial spin labeling (ASL), a magnetic resonance imaging technique, can be used to measure CBF without a contrast agent. We assessed CBF in patients with ICH using ASL and tested the hypothesis that CBF is related to systolic blood pressure (SBP).

Methods and Results

In this cross‐sectional study, patients with ICH were assessed with ASL at 48 hours, 7 days, and/or 30 days after onset. Relative CBF (rCBF; ratio of ipsilateral/contralateral perfusion) was measured in the perihematomal regions, hemispheres, border zones, and the perilesional area in patients with diffusion‐weighted imaging hyperintensities. Twenty‐patients (65% men; mean±SD age, 68.5±12.7 years) underwent imaging with ASL at 48 hours (N=12), day 7 (N=6), and day 30 (N=11). Median (interquartile range) hematoma volume was 13.1 (6.3–19.3) mL. Mean±SD baseline SBP was 185.4±25.5 mm Hg. Mean perihematomal rCBF was 0.9±0.2 at 48 hours at all time points. Baseline SBP and other SBP measurements were not associated with a decrease in rCBF in any of the regions of interest (P≥0.111). rCBF did not differ among time points in any of the regions of interest (P≥0.097). Mean perilesional rCBF was 1.04±0.65 and was unrelated to baseline SBP (P=0.105).

Conclusions

ASL can be used to measure rCBF in patients with acute and subacute ICH. Perihematomal CBF was not associated with SBP changes at any time point.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00963976.

Acute Blood Pressure Management in Neurocritically Ill Patients

Optimal blood pressure (BP) management is controversial in neurocritically ill patients due to conflicting concerns of worsening ischemia with decreased BP versus cerebral edema and increased intracranial pressure with elevated BP. In addition, high-quality evidence is lacking regarding optimal BP goals in patients with most of these conditions. This review summarizes guideline recommendations and examines the literature for BP management in patients with ischemic stroke, intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, traumatic brain injury, and spinal cord injury.

Blood Pressure Goals in Acute Stroke-How Low Do You Go?

PURPOSE OF REVIEW

Elevations in systolic blood pressure (BP) greater than 140 mmHg are reported in the majority (75%) of patients with acute ischemic stroke and in 80% of patients with acute intracerebral hemorrhages (ICH). This paper summarizes and updates the current knowledge regarding the proper management strategy for elevated BP in patients with acute stroke. Recent studies have generally showed a neutral effect of BP reduction on clinical outcomes among acute ischemic stroke patients. Thus, because of the lack of convincing evidence from clinical trials, aggressive BP reduction in patients presenting with acute ischemic stroke is currently not recommended. Although in patients treated with intravenous tissue plasminogen activator, guidelines are recommending BP < 180/105 mmHg but currently, the optimal BP management after reperfusion therapy still remains unclear. In acute ICH, the evidence from randomized clinical trials supports the immediate BP lowering targeting systolic BP to 140 mmHg, which is now recommended by guidelines.

Remote Diffusion-Weighted Imaging Lesions in Intracerebral Hemorrhage: Characteristics, Mechanisms, Outcomes, and Therapeutic Implications

Spontaneous intracerebral hemorrhage (ICH) is one of the most fatal form of stroke, with high mortality and disability rate. Small diffusion-weighed imaging lesions are not rare to see in regions remote from the hematoma after ICH and have been generally considered as related with poor outcome. In this review, we described the characteristics of remote ischemic lesions, discussed the possible mechanisms and clinical outcomes of these lesions, and evaluated the potential therapeutic implications.

Evolution of blood pressure management in acute intracerebral hemorrhage

Intracerebral hemorrhage (ICH) remains a prevalent and severe cause of death and disability worldwide. Control of the hypertensive response in acute ICH has been a mainstay of ICH management, yet the optimal approaches and the yield of recommended strategies have been difficult to establish despite a large body of literature. Over the years, theoretical and observed risks and benefits of intensive blood pressure reduction in ICH have been studied in the form of animal models, radiographic studies, and two recent large, randomized patient trials. In this article, we review the historical and developing data and discuss remaining questions surrounding blood pressure management in acute ICH.

Injury mechanisms in acute intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is the most common hemorrhagic stroke subtype, and rates are increasing with an aging population. Despite an increase in research and trials of therapies for ICH, mortality remains high and no interventional therapy has been demonstrated to improve outcomes. We review known mechanisms of injury, recent clinical trial results, and newly discovered signaling pathways involved in hematoma clearance. Enthusiasm remains high for methods of minimally invasive clot removal as well as pharmacologic strategies to improve recovery after ICH, both of which are currently being evaluated in clinical trials. This article is part of the Special Issue entitled 'Cerebral Ischemia'.

Secondary Hematoma Expansion and Perihemorrhagic Edema after Intracerebral Hemorrhage: From Bench Work to Practical Aspects

Intracerebral hemorrhages (ICH) represent about 10-15% of all strokes per year in the United States alone. Key variables influencing the long-term outcome after ICH are hematoma size and growth. Although death may occur at the time of the hemorrhage, delayed neurologic deterioration frequently occurs with hematoma growth and neuronal injury of the surrounding tissue. Perihematoma edema has also been implicated as a contributing factor for delayed neurologic deterioration after ICH. Cerebral edema results from both blood-brain barrier disruption and local generation of osmotically active substances. Inflammatory cellular mediators, activation of the complement, by-products of coagulation and hemolysis such as thrombin and fibrin, and hemoglobin enter the brain and induce a local and systemic inflammatory reaction. These complex cascades lead to apoptosis or neuronal injury. By identifying the major modulators of cerebral edema after ICH, a therapeutic target to counter degenerative events may be forthcoming.