Management of Acute Hypertensive Response in Intracerebral Hemorrhage Patients After ATACH-2 Trial

Statins and 90-Day Functional Performance and Survival in Patients with Spontaneous Intracerebral Hemorrhage

BACKGROUND

The neuroprotective effect of statins has become a focus of interest in spontaneous intracerebral hemorrhage (sICH). The purpose of this study was: (1) to evaluate the effect of statin use by the analyzed patients with sICH in the period preceding the onset of hemorrhage on their baseline neurological status and baseline neuroimaging of the head; (2) to evaluate the effect of statin use in the acute period of hemorrhage on the course and prognosis in the in-hospital period, taking into account whether the statin was taken before the hemorrhage or only after its onset; (3) to evaluate the effect of continuing statin treatment after in-hospital treatment on the functional performance and survival of patients up to 90 days after the onset of sICH symptoms, taking into account whether the statin was taken before the onset of sICH.

MATERIAL AND METHODS

A total of 153 patients diagnosed with sICH were analyzed, where group I were not previously taking a statin and group II were taking a statin before sICH onset. After lipidogram assessment, group I was divided into patients without dyslipidemia and without statin treatment (Ia) and patients with dyslipidemia who received de novo statin treatment during hospitalization (Ib). Group II patients continued taking statin therapy. We evaluated the effect of prior statin use on the severity of hemorrhage; the effect of statin use during the acute period of sICH on its in-hospital course; and the effect of statin treatment on the severity of neurological deficit, functional capacity and survival of patients up to 90 days after the onset of sICH symptoms.

RESULTS

There was no effect of prior statin use on the severity of hemorrhage as assessed clinically and by neuroimaging of the head. At in-hospital follow-up, subgroup Ia was the least favorable in terms of National Institutes of Health Stroke Scale (NIHSS) score. This subgroup had the highest percentage of deaths during hospitalization. In the post-hospital period, the greatest number of patients with improvement in the NIHSS, modified Rankin Scale (mRS) and Barthel scales were among those taking statins, especially group II patients. At 90-day follow-up, survival analysis fell significantly in favor of subgroup Ib and group II.

CONCLUSIONS

1. The use of statins in the pre-sICH period did not adversely affect the patients' baseline neurological status or the results of baseline neuroimaging studies. 2. Continued statin therapy prior to the onset of sICH or the inclusion of statins in acute treatment in patients with sICH and dyslipidemia does not worsen the course of the disease and the in-hospital prognosis. Statin therapy should not be discontinued during the acute phase of sICH. 3. To conclude the eventual beneficial effect on the functional performance and survival of patients after sICH onset, comparability of the analyzed groups in terms of clinical, radiological and other prognostic factors in spontaneous intracerebral hemorrhage would be needed. Future studies are needed to confirm these findings.

Adherence to Established Blood Pressure Targets and Associated Complications in Patients Presenting with Acute Intracerebral Hemorrhage

BACKGROUND

Conflicting evidence exists surrounding systolic blood pressure (SBP) control in patients with acute intracerebral hemorrhage (ICH). The 2022 American Heart Association and American Stroke Association guidelines recommend targeting a SBP of 140 mm Hg while maintaining the range of 130-150 mm Hg. The current practice at our health system is to titrate antihypertensives to a SBP goal of < 160 mm Hg, which aligns with previous recommendations. We hypothesized that the prior lack of guidance to a specific SBP target range predisposed patients to hypotension leading to an increased risk of brain and renal adverse events.

METHODS

This retrospective, multicenter, single health system cohort study included adults admitted to the neurointensive care unit or intermediate unit with acute ICH from June 2019 to June 2021. The primary objective evaluated the frequency of time within SBP range (140-160 mm Hg) in the first 48 h. Secondary and safety end points included the frequency of time above and below the established SBP range, episodes of hypotension (defined as a decrease in SBP < 140 mm Hg prompting discontinuation in antihypertensive[s] or the initiation of vasopressor[s]), the incidence of new brain or renal adverse events within 7 days, and modified Rankin Scale at discharge.

RESULTS

A total of 80 patients (59% men; median age 62 years) were included. The majority of ICHs in this cohort were intraparenchymal (70%). Nearly one third were attributed to systemic hypertension (31%). During the first 48 h of admission, the frequency of time spent above, within, and below the target SBP range were 6 h (12%), 16 h (34%), and 26 h (54%), respectively. Hypotension was associated with renal adverse events (odds ratio [OR] 3.36, 95% confidence interval [CI] 1.10-11.44, p = 0.023). A relative SBP reduction > 20% in the first 48 h was associated with renal adverse events (OR 8.99, 95% CI 2.57-35.25, p < 0.001), brain ischemia (OR 22.5, 95% CI 1.92-300.11, p = 0.005), and an increased odd of a modified Rankin Scale of 4-6 at discharge (OR 11.79, 95% CI 2.79-57.02, p < 0.001).

CONCLUSIONS

In individuals with nontraumatic/nonaneurysmal ICH, SBP measurements were observed to be < 140 mm Hg for > 50% of the initial 48 h following admission. Hypotension and relative SBP reduction > 20% were also independent predictors of renal adverse events. SBP reduction > 20% was also an independent predictor of brain ischemia. These data indicate that intensive SBP reduction following ICH predispose patients to secondary organ injury that may impact long-term outcomes. Our data suggest that a more modest lowering of the SBP within 48 h, as recommended in the most recent guidelines, may minimize the risk of further adverse events.

Hypertensive intracerebral hemorrhage: Which one should we choose between laser navigation and 3D navigation mold?

Background

Hypertensive intracerebral hemorrhage (HICH) is a severe life-threatening disease, and its incidence has gradually increased in recent years. Due to the particularity and diversity of its bleeding sites, the early treatment of hematoma needs to be more meticulous and accurate, and minimally invasive surgery is often one of the measures that are commonly adopted now. The lower hematoma debridement and the navigation template created by 3D printing technology were compared in the external drainage of a hypertensive cerebral hemorrhage. Then the effect and feasibility of the two operations were explicitly evaluated.

Material and methods

We performed a retrospective analysis of all eligible patients with HICH who underwent laser-guided hematoma evacuation or hematoma puncture under 3D-navigated molds at the Affiliated Hospital of Binzhou Medical University from January 2019 to January 2021. A total of 43 patients were treated. Twenty-three patients were treated with laser navigation-guided hematoma evacuation (group A); 20 patients were treated with 3D navigation minimally invasive surgery (group B). A comparative study was conducted between the two groups to evaluate the preoperative and postoperative conditions.

Results

The preoperative preparation time of the laser navigation group was significantly shorter than that of the 3D printing group. The operation time of the 3D printing group was better than that of the laser navigation group (0.73 ± 0.26 h vs. 1.03 ± 0.27 h P = 0.00070). In the improvement in the short-term postoperatively, there was no statistically significant difference between the laser navigation group and the 3D printing group (Median hematoma evacuation rate P = 0.14); And in the three-month follow-up NIHESS score, there was no significant difference between the two (P = 0.82).

Conclusion

Laser-guided hematoma removal is more suitable for emergency operations, with real-time navigation and shortened preoperative preparation time; hematoma puncture under a 3D navigation mold is more personalized and shortens the intraoperative time course. There was no significant difference in therapeutic effect between the two groups.

Molecular, Pathological, Clinical, and Therapeutic Aspects of Perihematomal Edema in Different Stages of Intracerebral Hemorrhage

Acute intracerebral hemorrhage (ICH) is a devastating type of stroke worldwide. Neuronal destruction involved in the brain damage process caused by ICH includes a primary injury formed by the mass effect of the hematoma and a secondary injury induced by the degradation products of a blood clot. Additionally, factors in the coagulation cascade and complement activation process also contribute to secondary brain injury by promoting the disruption of the blood-brain barrier and neuronal cell degeneration by enhancing the inflammatory response, oxidative stress, etc. Although treatment options for direct damage are limited, various strategies have been proposed to treat secondary injury post-ICH. Perihematomal edema (PHE) is a potential surrogate marker for secondary injury and may contribute to poor outcomes after ICH. Therefore, it is essential to investigate the underlying pathological mechanism, evolution, and potential therapeutic strategies to treat PHE. Here, we review the pathophysiology and imaging characteristics of PHE at different stages after acute ICH. As illustrated in preclinical and clinical studies, we discussed the merits and limitations of varying PHE quantification protocols, including absolute PHE volume, relative PHE volume, and extension distance calculated with images and other techniques. Importantly, this review summarizes the factors that affect PHE by focusing on traditional variables, the cerebral venous drainage system, and the brain lymphatic drainage system. Finally, to facilitate translational research, we analyze why the relationship between PHE and the functional outcome of ICH is currently controversial. We also emphasize promising therapeutic approaches that modulate multiple targets to alleviate PHE and promote neurologic recovery after acute ICH.

Comparison of Clinical Efficacy of Sodium Nitroprusside and Urapidil in the Treatment of Acute Hypertensive Cerebral Hemorrhage

This paper mainly studies the clinical efficacy of sodium nitroprusside and urapidil in the treatment of acute hypertensive intracerebral hemorrhage and analyzes the brain CT image detection based on a deep learning algorithm. A total of 132 cases of acute hypertension admitted to XXX hospital from XX 2019 to XX 2020 were retrospectively analyzed. The diseases of all patients were clinically confirmed, and patients were divided into groups according to the differences in treatment methods. Urapidil was used for group 1; sodium nitroprusside was used for group 2; and urapidil combined with sodium nitroprusside was used for group 3. A convolutional neural network in deep learning is used to construct intelligent processing to classify brain CT images of patients. The network performance of AlexNet, GoogLeNet, and CNN3 is predicted. The results show that GoogLeNet has the highest prediction accuracy of 0.83, followed by AlexNet with 0.80 and CNN3 with 0.74. The results of the performance parameter curve show that the GoogLeNet has the highest performance parameter of 0.89, followed by AlexNet and CNN3 network. The performance parameter curve of machine learning is above 0.80. After five weeks of drug treatment, the hematoma volume was (3.8 ± 2.6) mL in group1, (7.6 ± 2.8) mL in group 2, and (2.8 ± 1.5) mL in group 3. After 5 days of treatment, the patients' heart rate changed compared with before treatment. Compared with group 2, there were significant differences between groups 1 and 3 (P < 0.01), indicating that the therapeutic effect of the combination group was significantly better than that of the other groups alone. In summary, the combination of sodium nitroprusside and urapidil has a significantly better effect than that of urapidil alone. A convolutional neural network based on deep learning improves the recognition accuracy of medical images.

Intracerebral Hemorrhage: A Common yet Disproportionately Deadly Stroke Subtype

Spontaneous intracerebral hemorrhage (ICH) is a medical emergency and is disproportionately associated with higher mortality and long-term disability compared with ischemic stroke. The phrase "time is brain" was derived for patients with large vessel occlusion ischemic stroke in which approximately 1.9 million neurons are lost every minute. Similarly, this statement holds true for ICH patients due to a high volume of neurons that are damaged at initial onset and during hematoma expansion. Most cases of spontaneous ICH pathophysiologically stem from chronic hypertension and rupture of small perforating vessels off of larger cerebral arteries supplying deep brain structures, with cerebral amyloid angiopathy being another cause for lobar hemorrhages in older patients. Optimal ICH medical management strategies include timely diagnosis, aggressive blood pressure control, correction of underlying coagulopathy defects if present, treatment of cerebral edema, and continuous assessment for possible surgical intervention. Current strategies in the surgical management of ICH include newly developed minimally invasive techniques for hematoma evacuation, with the goal of mitigating injury to fiber tracts while accessing the clot. We review evidence-based medical and surgical management of spontaneous ICH with the overall goal of reducing neurologic injury and optimizing functional outcome.

Efficacy of minimally invasive surgery for the treatment of hypertensive intracerebral hemorrhage: A protocol of randomized controlled trial

INTRODUCTION

Hypertensive intracerebral hemorrhage (HICH) is the most serious complication of hypertension. Clearing intracranial hematoma as soon as possible, reducing brain cell edema, and controlling intracranial pressure could effectively reduce neuron damage, lower patient mortality, and improve patient prognosis. At present, minimally invasive surgery (MIS) has been widely used and plays an important role in the treatment of HICH. However, it is still in controversies about the choice of surgical treatment and medication treatment for HICH. Therefore, we try to conduct a randomized, controlled, prospective trial to observe the efficacy of MIS treatment against HICH compared with medication treatment.

METHODS

Patients will be randomly divided into treatment group and control group in a 1:1 ratio using the random number generator in Microsoft Excel. Stereotactic soft channel minimally invasive intracranial hematoma puncture and drainage treatment and medication treatment will be applied respectively. The outcomes of intracerebral hemorrhage volume, Glasgow coma scale, National Institutes of Health Stroke Scale will be recorded.

CONCLUSIONS

The findings of the study will be helpful for the choice of MIS and conservative treatment when treating HICH patients.

TRIAL REGISTRATION

OSF Registration number: DOI 10.17605/OSF.IO/ME6Y5.

Translational Intracerebral Hemorrhage Research: Has Current Neuroprotection Research ARRIVEd at a Standard for Experimental Design and Reporting?

One major aim of preclinical intracerebral hemorrhage (ICH) research is to develop and test potential neuroprotectants. Published guidelines for experimental design and reporting stress the importance of clearly and completely reporting results and methodological details to ensure reproducibility and maximize information availability. The current review has two objectives: first, to characterize current ICH neuroprotection research and, second, to analyze aspects of translational design in preclinical ICH studies. Translational design is the adoption and reporting of experimental design characteristics that are thought to be clinically relevant and critical to reproducibility in animal studies (e.g., conducting and reporting experiments according to the STAIR and ARRIVE guidelines, respectively). Given that ICH has no current neuroprotective treatments and an ongoing reproducibility crisis in preclinical research, translational design should be considered by investigators. We conducted a systematic review of ICH research from 2015 to 2019 using the PubMed database. Our search returned 281 published manuscripts studying putative neuroprotectants in animal models. Contemporary ICH research predominantly uses young, healthy male rodents. The collagenase model is the most commonly used. Reporting of group sizes, blinding, and randomization are almost unanimous, but group size calculations, mortality and exclusion criteria, and animal model characteristics are infrequently reported. Overall, current ICH neuroprotection research somewhat aligns with experimental design and reporting guidelines. However, there are areas for improvement. Because failure to consider translational design is associated with inflation of effect sizes (and possibly hindered reproducibility), we suggest that researchers, editors, and publishers collaboratively consider enhanced adherence to published guidelines.

Ultra-Early Blood Pressure Reduction Attenuates Hematoma Growth and Improves Outcome in Intracerebral Hemorrhage

OBJECTIVE

The aim was to investigate whether intensive blood pressure treatment is associated with less hematoma growth and better outcome in intracerebral hemorrhage (ICH) patients who received intravenous nicardipine treatment ≤2 hours after onset of symptoms.

METHODS

A post-hoc exploratory analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial was performed. This was a multicenter, international, open-label, randomized clinical trial, in which patients with primary ICH were allocated to intensive versus standard blood pressure treatment with nicardipine ≤4.5 hours after onset of symptoms. We have included 913 patients with complete imaging and follow-up data in the present analysis.

RESULTS

Among the 913 included patients, 354 (38.7%) had intravenous nicardipine treatment initiated within 2 hours. In this subgroup of patients treated within 2 hours, the frequency of ICH expansion was significantly lower in the intensive blood pressure reduction group compared with the standard treatment group (p = 0.02). Multivariable analysis showed that ultra-early intensive blood pressure treatment was associated with a decreased risk of hematoma growth (odds ratio, 0.56; 95% confidence interval [CI], 0.34-0.92; p = 0.02), higher rate of functional independence (odds ratio, 2.17; 95% CI, 1.28-3.68; p = 0.004), and good outcome (odds ratio, 1.68; 95% CI, 1.01-2.83; p = 0.048) at 90 days. Ultra-early intensive blood pressure reduction was associated with a favorable shift in modified Rankin Scale score distribution at 3 months (p = 0.04).

INTERPRETATION

In a subgroup of ICH patients with elevated blood pressure given intravenous nicardipine ≤2 hours after onset of symptoms, intensive blood pressure reduction was associated with reduced hematoma growth and improved functional outcome. ANN NEUROL 2020;88:388-395.

Integration of Computed Tomographic Angiography Spot Sign and Noncontrast Computed Tomographic Hypodensities to Predict Hematoma Expansion

Background and Purpose- Noncontrast computed tomographic (CT) hypodensities represent an alternative to the CT angiography spot sign (SS) to predict intracerebral hemorrhage (ICH) expansion. However, previous studies suggested that these markers predicted hematoma expansion independently from each other. We investigated whether the integration of SS and hypodensity (HD) improved the stratification of ICH expansion risk. Methods- A single-center cohort of consecutive patients with ICH was retrospectively analyzed. Patients with available CT angiography, baseline, and follow-up noncontrast CT images available were included. Trained readers reviewed all the images for SS and HD presence, and the study population was classified into 4 groups: SS and HD negative (SS-HD-), SS positive only (SS+HD-), HD positive only (SS-HD+), and SS and HD positive (SS+HD+). ICH expansion was defined as hematoma growth >33% or >6 mL. The association between SS and HD presence and ICH expansion was investigated with multivariable logistic regression. Results- A total of 745 subjects qualified for the analysis (median age, 73 years; 54.1% men). The rates of ICH expansion were 9.3% in SS-HD-, 25.8% in SS+HD-, 27.4% in SS-HD+, and 55.6% in SS+HD+ patients ( P<0.001). After adjustment for potential confounders and keeping SS-HD- subjects as reference, the risk of ICH expansion was increased in SS+HD- and SS-HD+ patients (odds ratio, 2.93, P=0.002 and odds ratio, 3.02, P<0.001, respectively). SS+HD+ subjects had the highest risk of hematoma growth (odds ratio, 9.50; P<0.001). Conclusions- Integration of SS and HD improves the stratification of hematoma growth risk and may help the selection of patients with ICH for antiexpansion treatment in clinical trials.

Early Prediction of Prognosis in Elderly Acute Stroke Patients

Acute stroke has a high morbidity and mortality in elderly population. Baseline confounding illnesses, initial clinical examination, and basic laboratory tests may impact prognostics. In this study, we aimed to establish a model for predicting in-hospital mortality based on clinical data available within 12 hours of hospital admission in elderly (≥ 65 age) patients who experienced stroke.

DESIGN

Retrospective observational cohort study.

SETTING

Academic comprehensive stroke center.

PATIENTS

Elderly acute stroke patients-2005-2009 (n = 462), 2010-2012 (n = 122), and 2016-2017 (n = 123).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

After institutional review board approval, we retrospectively queried elderly stroke patients' data from 2005 to 2009 (training dataset) to build a model to predict mortality. We designed a multivariable logistic regression model as a function of baseline severity of illness and laboratory tests, developed a nomogram, and applied it to patients from 2010 to 2012. Due to updated guidelines in 2013, we revalidated our model (2016-2017). The final model included stroke type (intracerebral hemorrhage vs ischemic stroke: odds ratio [95% CI] of 0.92 [0.50-1.68] and subarachnoid hemorrhage vs ischemic stroke: 1.0 [0.40-2.49]), year (1.01 [0.66-1.53]), age (1.78 [1.20-2.65] per 10 yr), smoking (8.0 [2.4-26.7]), mean arterial pressure less than 60 mm Hg (3.08 [1.67-5.67]), Glasgow Coma Scale (0.73 [0.66-0.80] per 1 point increment), WBC less than 11 K (0.31 [0.16-0.60]), creatinine (1.76 [1.17-2.64] for 2 vs 1), congestive heart failure (2.49 [1.06-5.82]), and warfarin (2.29 [1.17-4.47]). In summary, age, smoking, congestive heart failure, warfarin use, Glasgow Coma Scale, mean arterial pressure less than 60 mm Hg, admission WBC, and creatinine levels were independently associated with mortality in our training cohort. The model had internal area under the curve of 0.83 (0.79-0.89) after adjustment for over-fitting, indicating excellent discrimination. When applied to the test data from 2010 to 2012, the nomogram accurately predicted mortality with area under the curve of 0.79 (0.71-0.87) and scaled Brier's score of 0.17. Revalidation of the same model in the recent dataset from 2016 to 2017 confirmed accurate prediction with area under the curve of 0.83 (0.75-0.91) and scaled Brier's score of 0.27.

CONCLUSIONS

Baseline medical problems, clinical severity, and basic laboratory tests available within the first 12 hours of admission provided strong independent predictors of in-hospital mortality in elderly acute stroke patients. Our nomogram may guide interventions to improve acute care of stroke.

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-Attained Analysis of ATACH 2 Trial

BACKGROUND AND PURPOSE

We compared the rates of death or disability, defined by modified Rankin Scale score of 4 to 6, at 3 months in patients with intracerebral hemorrhage according to post-treatment systolic blood pressure (SBP)-attained status.

METHODS

We divided 1000 subjects with SBP ≥180 mm Hg who were randomized within 4.5 hours of symptom onset as follows: SBP <140 mm Hg achieved or not achieved within 2 hours; subjects in whom SBP <140 mm Hg was achieved within 2 hours were further divided: SBP <140 mm Hg for 21 to 22 hours (reduced and maintained) or SBP was ≥140 mm Hg for at least 2 hours during the period between 2 and 24 hours (reduced but not maintained).

RESULTS

Compared with subjects without reduction of SBP <140 mm Hg within 2 hours, subjects with reduction and maintenance of SBP <140 mm Hg within 2 hours had a similar rate of death or disability (relative risk of 0.98; 95% confidence interval, 0.74-1.29). The rates of neurological deterioration within 24 hours were significantly higher in reduced and maintained group (10.4%; relative risk, 1.98; 95% confidence interval, 1.08-3.62) and in reduced but not maintained group (11.5%; relative risk, 2.08; 95% confidence interval, 1.15-3.75) compared with reference group. The rates of cardiac-related adverse events within 7 days were higher among subjects with reduction and maintenance of SBP <140 mmHg compared to subjects without reduction (11.2% versus 6.4%).

CONCLUSIONS

No decline in death or disability but higher rates of neurological deterioration and cardiac-related adverse events were observed among intracerebral hemorrhage subjects with reduction with and without maintenance of intensive SBP goals.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01176565.

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.