Effect of Treatment of Elevated Blood Pressure on Neurological Deterioration in Patients with Acute Intracerebral Hemorrhage

Neurocritical Care (Impact Factor: 2.44). 10/2008; 9(2):177-182. DOI: 10.1007/s12028-008-9106-7


IntroductionTreatment of elevated blood pressure after acute intracerebral hemorrhage (ICH) is controversial. There is a risk of hematoma
expansion with elevated blood pressure, and risk of ischemia with blood pressure control. This study was done to determine
the effect of blood pressure control on outcome.

MethodsWe retrospectively studied 122 patients with ICH. We collected 24-h blood pressure readings on all patients. The Glasgow Coma
Score (GCS) at baseline and at 24h was used to determine neurological deterioration (GCS decline≥2). Baseline computerized
tomography (CT) scans were reviewed for hematoma volume, intraventricular hemorrhage, and location of hemorrhage. Drops in
systolic blood pressure and mean arterial pressures over 24h were divided in quartiles to determine the risk of neurological
deterioration among quartiles. A logistic regression model was used to determine the association between variables of interest
and neurological deterioration.

ResultsNeurological deterioration was observed in 12 patients (10%). Baseline blood pressure and GCS were only two variables significantly
different among quartiles of blood pressure drop. Multivariable adjusted analysis for these variables demonstrated significant
trend toward reduced neurological deterioration with maximum blood pressure drop (systolic or mean). The risk of neurological
deterioration was significantly lower in the quartile of maximum drop of systolic (odds ratio [OR] 0.02, 95% confidence interval
[CI] 0.0–0.68) or mean (OR 0.03, 95% CI 0.0–0.98) blood pressure when compared to the quartile with least drop.

ConclusionThis study supports that reduction of blood pressure in patients with acute ICH is safe and suggests that aggressive reduction
might reduce the risk of neurological deterioration in first 24h of admission.

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    ABSTRACT: Intracerebral hemorrhage (ICH) is a poorly understood condition with devastating results. Despite the personal and social impact of ICH, modern medicine can offer little hope. Surgery is the longest-standing therapy, but with no demonstrated evidence of positive effect. Reduction of the early hypertension seen with ICH is believed to limit hematoma growth and improve clinical outcome. The effectiveness and safety of an early, aggressive blood-pressure-lowering strategy for ICH patients has only recently been examined in randomized controlled trials. Does early, intensive lowering of blood pressure reduce hematoma volume and improve clinical outcome after acute cerebral hemorrhage? Evidence Two trials assessing the clinical impact of blood pressure lowering in intracerebral hemorrhage were acquired and appraised. The two randomized trials incorporated similar parallel designs and both trials measured clinical outcomes and short-term change in hematoma size. The smaller trial was only partially blinded and showed no difference in any of the outcomes; the large trial demonstrated marginal reduction in proportional hematoma growth, but no significant difference in clinical outcome. There is currently insufficient evidence to support the routine practice of lowering blood pressure of patients suffering an acute intracerebral hemorrhage.
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