Intensive Blood Pressure Reduction After ICH Not Linked to Ischemic Lesions
Intensive systolic blood pressure (SBP) lowering after intracerebral hemorrhage (ICH) does not increase the risk of ischemic brain injury, according to a new randomized clinical trial published in JAMA Neurology.
“These results support the safety of early blood pressure reduction in acute ICH,” Ken Butcher, MD, PhD, School of Clinical Medicine, University of New South Wales, Sydney, Australia, and co-authors said in the study.
The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial 2 (ICHADAPT-2) evaluated the impact of SBP targets <140 mm Hg versus <180 mm Hg on the development of diffusion-weighted imaging (DWI) lesions within 48 hours of ICH.
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In the trial, 162 patients with acute spontaneous ICH were enrolled across 4 sites in Canada and Australia. Of those participants, 78 were included in the primary analysis and randomized into 2 groups, both of which underwent a 48-hour MRI. DWI lesions were observed in 31% of those in the <140 mm Hg group and 38% in the <180 mm Hg group (OR, 0.74; P = .32). The median number of lesions and total DWI lesion volume were similar between groups, with most lesions measuring under 1 mL. Mean SBP was lower over the 48-hour period after randomization in the <140 mm Hg group (mean difference, 18.9 mm Hg [95% CI, 17.6-20.2]; P < .001).
Adverse event and mortality rates did not differ significantly between groups. In the <140 mm group, however, 2 patients developed ischemic stroke.
Exploratory analysis identified ICH volume, rather than SBP reduction, as the only independent predictor of DWI lesion incidence (OR, 1.04 [95% CI, 1.01-1.07]; P = .02).
“All DWI lesions were asymptomatic, reflecting both their small volumes and the baseline neurological deficits related to the index ICH. There is some evidence that long-term morbidity and mortality are elevated in patients with ICH with DWI lesions, but the causal association, if any, remains unknown,” authors said.
Authors noted a few study limitations, including an insufficient sample size that did not allow for conclusive rejection of the null hypothesis regarding DWI lesion increases. There was also a selection bias, with patients experiencing larger ICH volumes and more severe neurological disabilities less likely to undergo DWI, leading to over half of the randomized patients missing the primary endpoint. Additionally, the study did not investigate potential embolic sources or other etiological factors linked to DWI lesions, such as leukoaraiosis and cerebral microbleeds.
“Ongoing uncertainties about the true frequency of DWI lesions after ICH, their association with acute interventions, and outcomes may be addressed in the future if routine early MRI scans become part of ongoing ICH registries and practice guidelines,” authors concluded.
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