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Wang CY, Lai SZ, Kang BC, Lin YZ, Cao CJ, Huang XB, Wang JQ. Association of pulse pressure with hematoma expansion in patients with spontaneous supratentorial intracerebral hemorrhage. Front Neurol 2024; 15:1374198. [PMID: 38813243 PMCID: PMC11133623 DOI: 10.3389/fneur.2024.1374198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 04/26/2024] [Indexed: 05/31/2024] Open
Abstract
Objective Recent reports have demonstrated that a wider pulse pressure upon admission is correlated with heightened in-hospital mortality following spontaneous supratentorial intracerebral hemorrhage (ssICH). However, the underlying mechanism remains ambiguous. We investigated whether a wider pulse pressure was associated with hematoma expansion (HE). Methods Demographic information, clinical features, and functional outcomes of patients diagnosed with ssICH were retrospectively collected and analyzed. Multivariate logistic regression was conducted to identify independent predictors of HE. Weighted logistic regression, restricted cubic spline models, and propensity score matching (PSM) were employed to estimate the association between pulse pressure and HE. Results We included 234 eligible adult ssICH patients aged 60 (51-71) years, and 55.56% were male. The mean pulse pressure was 80.94 ± 23.32 mmHg. Twenty-seven patients (11.54%) developed early HE events, and 116 (49.57%) experienced a poor outcome (modified Rankin scale 3-6). A wider mean pulse pressure as a continuous variable was a predictor of HE [odds ratios (OR) 1.026, 95% confidence interval (CI) 1.007-1.046, p = 0.008] in multivariate analysis. We transformed pulse pressure into a dichotomous variable based on its cutoff value. After adjusting for confounding of HE variables, the occurrence of HE in patients with ssICH with wider pulse pressure levels (≥98 mmHg) had 3.78 times (OR 95% CI 1.47-9.68, p = 0.006) compared to those with narrower pulse pressure levels (<98 mmHg). A linear association was observed between pulse pressure and increased HE risk (P for overall = 0.036, P for nonlinear = 0.759). After 1:1 PSM (pulse pressure ≥98 mmHg vs. pulse pressure <98 mmHg), the rates of HE events and poor outcome still had statistically significant in wider-pulse pressure group [HE, 12/51 (23.53%) vs. 4/51 [7.84%], p = 0.029; poor outcome, 34/51 (66.67%) vs. 19/51 (37.25%), p = 0.003]. Conclusion Widened acute pulse pressure (≥98 mmHg) levels at admission are associated with increased risks of early HE and unfavorable outcomes in patients with ssICH.
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Affiliation(s)
- Chao-Ying Wang
- Department of Neurosurgery, Dehua County Hospital, Quanzhou, China
| | - Su-Zhen Lai
- Department of Imaging, Dehua County Hospital, Quanzhou, China
| | - Bao-Cai Kang
- Department of Internal Medicine, Dehua County Hospital, Quanzhou, China
- Department of Geriatrics, Changji People’s Hospital, Changji, China
| | - Yi-Zhao Lin
- Department of Laboratory Medicine, Dehua County Hospital, Quanzhou, China
| | - Chun-Juan Cao
- Department of Imaging, Dehua County Hospital, Quanzhou, China
| | - Xin-Bing Huang
- Department of Neurology, Dehua County Hospital, Quanzhou, China
| | - Jian-Qun Wang
- Department of Neurosurgery, Dehua County Hospital, Quanzhou, China
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Huang YH, Lee TH, Ting CW. Exploring the relationship between admission pulse pressure and clinical features in patients with spontaneous supratentorial intracerebral hemorrhage. Neurosurg Rev 2023; 47:19. [PMID: 38135792 DOI: 10.1007/s10143-023-02256-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 12/24/2023]
Abstract
Elevated pulse pressure is commonly observed in cardiovascular diseases and serves as an independent risk factor and predictor of cardiac mortality. However, the role of pulse pressure in patients with spontaneous intracerebral hemorrhage (ICH) remains uncertain. This study aimed to investigate the association between admission pulse pressure and clinical characteristics, including in-hospital outcomes, in ICH patients. We retrospectively analyzed the data of 292 ICH patients, categorizing them into two groups based on admission wide pulse pressure: > 100 mmHg (n = 60) and ≤ 100 mmHg (n = 232). Clinical characteristics and in-hospital outcomes were compared between the groups, and multivariate logistic regression was performed to identify independent factors. Patients with wide pulse pressure were older, had lower Glasgow Coma Scale, larger intraparenchymal hematomas, more pronounced midline shifts, and higher rates of intraventricular hematoma extension and hydrocephalus. These patients also experienced higher frequencies of craniotomy or craniectomy and longer hospital stays. Multivariate logistic regression revealed that pulse pressure > 100 mmHg was significantly associated with increased in-hospital mortality (odds ratio 4.31, 95% confidence interval 1.12-16.62, p = 0.03), but not with a modified Rankin Scale score of 4-6. In conclusion, our investigation demonstrates a significant relationship between admission pulse pressure and severe clinical characteristics in ICH patients. Importantly, a wider pulse pressure is linked to heightened in-hospital mortality. These results underscore the necessity for customized strategies to predict patient outcomes in this population. Further research is essential to explore potential therapeutic interventions targeting pulse pressure to improve clinical outcomes for ICH patients.
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Affiliation(s)
- Yu-Hua Huang
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsung-Han Lee
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chun-Wei Ting
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Rehni AK, Cho S, Quero HN, Zhang Z, Dong C, Zhao W, Perez-Pinzon MA, Koch S, Jy W, Dave KR. Red Blood Cell Microparticles Limit Hemorrhage Following Intracerebral Hemorrhage in Spontaneously Hypertensive Rats. Stroke 2023; 54:e152-e154. [PMID: 36861474 PMCID: PMC10050095 DOI: 10.1161/strokeaha.122.042152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Affiliation(s)
- Ashish K. Rehni
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sunjoo Cho
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hever Navarro Quero
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Zhexuan Zhang
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL, USA
| | - Chuanhui Dong
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Weizhao Zhao
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL, USA
| | - Miguel A. Perez-Pinzon
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
- Neuroscience Program, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Wenche Jy
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kunjan R. Dave
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
- Neuroscience Program, University of Miami Miller School of Medicine, Miami, FL, USA
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Xu X, Peng S, Zhou Y, Li J, Tong L, Gao F. Remote diffusion-weighted imaging lesions and blood pressure variability in primary intracerebral hemorrhage. Front Neurol 2022; 13:950056. [PMID: 36203972 PMCID: PMC9530136 DOI: 10.3389/fneur.2022.950056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe 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).MethodsWe 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).ResultsRemote 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.ConclusionOur results provided additional evidence that BPV is associated with the development of R-DWILs in primary ICH.
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Affiliation(s)
- Xuhua Xu
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Neurology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Shuangshuang Peng
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Neurology, Taizhou First People's Hospital, Taizhou, China
| | - Yanli Zhou
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Neurology, Taizhou First People's Hospital, Taizhou, China
| | - Jiawen Li
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lusha Tong
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Lusha Tong
| | - Feng Gao
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Feng Gao
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Mullen MT, Anderson CS. Review of Long-Term Blood Pressure Control After Intracerebral Hemorrhage: Challenges and Opportunities. Stroke 2022; 53:2142-2151. [PMID: 35657328 DOI: 10.1161/strokeaha.121.036885] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood pressure (BP) is the most important modifiable risk factor for intracerebral hemorrhage (ICH). Elevated BP is associated with an increased risk of ICH, worse outcome after ICH, and in survivors, higher risks of recurrent ICH, ischemic stroke, myocardial infarction, and cognitive impairment/dementia. As intensive BP control probably improves the chances of recovery from acute ICH, the early use of intravenous or oral medications to achieve a systolic BP goal of <140 mm Hg within the first few hours of presentation is reasonable for being applied in most patients. In the long-term, oral antihypertensive drugs should be titrated as soon as possible to achieve a goal BP <130/80 mm Hg and again in all ICH patients regardless of age, location, or presumed mechanism of ICH. The degree of sustained BP reduction, rather than the choice of BP-lowering agent(s), is the most important factor for optimizing risk reduction, with varying combinations of thiazide-type diuretics, long-acting calcium channel blockers, ACE (angiotensin-converting enzyme) inhibitors or angiotensin receptor blockers, being the mainstay of therapy. As most patients will require multiple BP-lowering agents, and physician inertia and poor adherence are major barriers to effective BP control, single-pill combination therapy should be considered as the choice of management where available. Increased population and clinician awareness, and innovations to solving patient, provider, and social factors, have much to offer for improving BP control after ICH and more broadly across high-risk groups. It is critical that all physicians, especially those managing ICH patients, emphasize the importance of BP control in their practice.
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Affiliation(s)
- Michael T Mullen
- Department of Neurology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA (M.T.M.)
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.S.A.).,The George Institute China at Peking University Health Sciences Center, Beijing (C.S.A.)
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Guo QH, Liu CH, Wang JG. Blood Pressure Goals in Acute Stroke. Am J Hypertens 2022; 35:483-499. [PMID: 35323883 PMCID: PMC9203067 DOI: 10.1093/ajh/hpac039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 03/17/2022] [Accepted: 03/19/2022] [Indexed: 01/27/2023] Open
Abstract
Antihypertensive treatment is highly effective in both primary and secondary prevention of stroke. However, current guideline recommendations on the blood pressure goals in acute stroke are clinically empirical and generally conservative. Antihypertensive treatment is only recommended for severe hypertension. Several recent observational studies showed that the relationship between blood pressure and unfavorable clinical outcomes was probably positive in acute hemorrhagic stroke but J- or U-shaped in acute ischemic stroke with undetermined nadir blood pressure. The results of randomized controlled trials are promising for blood pressure management in hemorrhagic stroke but less so in ischemic stroke. A systolic blood pressure goal of 140 mm Hg is probably appropriate for acute hemorrhagic stroke. The blood pressure goal in acute ischemic stroke, however, is uncertain, and probably depends on the time window of treatment and the use of revascularization therapy. Further research is required to investigate the potential benefit of antihypertensive treatment in acute stroke, especially with regard to the possible reduction of blood pressure variability and more intensive blood pressure lowering in the acute and subacute phases of a stroke, respectively.
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Affiliation(s)
- Qian-Hui Guo
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chu-Hao Liu
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Melmed KR, Carroll E, Lord AS, Boehme AK, Ishida K, Zhang C, Torres JL, Yaghi S, Czeisler BM, Frontera JA, Lewis A. Systemic Inflammatory Response Syndrome is Associated with Hematoma Expansion in Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105870. [PMID: 34077823 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/26/2021] [Accepted: 05/02/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Systemic inflammatory response syndrome (SIRS) and hematoma expansion are independently associated with worse outcomes after intracerebral hemorrhage (ICH), but the relationship between SIRS and hematoma expansion remains unclear. MATERIALS AND METHODS We performed a retrospective review of patients admitted to our hospital from 2013 to 2020 with primary spontaneous ICH with at least two head CTs within the first 24 hours. The relationship between SIRS and hematoma expansion, defined as ≥6 mL or ≥33% growth between the first and second scan, was assessed using univariable and multivariable regression analysis. We assessed the relationship of hematoma expansion and SIRS on discharge mRS using mediation analysis. RESULTS Of 149 patients with ICH, 83 (56%; mean age 67±16; 41% female) met inclusion criteria. Of those, 44 (53%) had SIRS. Admission systolic blood pressure (SBP), temperature, antiplatelet use, platelet count, initial hematoma volume and rates of infection did not differ between groups (all p>0.05). Hematoma expansion occurred in 15/83 (18%) patients, 12 (80%) of whom also had SIRS. SIRS was significantly associated with hematoma expansion (OR 4.5, 95% CI 1.16 - 17.39, p= 0.02) on univariable analysis. The association remained statistically significant after adjusting for admission SBP and initial hematoma volume (OR 5.72, 95% CI 1.40 - 23.41, p= 0.02). There was a significant indirect effect of SIRS on discharge mRS through hematoma expansion. A significantly greater percentage of patients with SIRS had mRS 4-6 at discharge (59 vs 33%, p=0.02). CONCLUSION SIRS is associated with hematoma expansion of ICH within the first 24 hours, and hematoma expansion mediates the effect of SIRS on poor outcome.
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Affiliation(s)
- Kara R Melmed
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA; Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA.
| | - Elizabeth Carroll
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Aaron S Lord
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Amelia K Boehme
- Department of Epidemiology and Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Koto Ishida
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Cen Zhang
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Jose L Torres
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Shadi Yaghi
- Department of Neurology, Brown University School of Medicine, Providence, RI, USA
| | - Barry M Czeisler
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA; Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Jennifer A Frontera
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA; Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
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Hawkes MA, Rabinstein AA. Acute Hypertensive Response in Patients With Acute Intracerebral Hemorrhage: A Narrative Review. Neurology 2021; 97:316-329. [PMID: 34031208 DOI: 10.1212/wnl.0000000000012276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/23/2021] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Maximiliano A Hawkes
- From the Department of Neurological Sciences (M.A.H.), University of Nebraska Medical Center, Omaha; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN.
| | - Alejandro A Rabinstein
- From the Department of Neurological Sciences (M.A.H.), University of Nebraska Medical Center, Omaha; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
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Neurological Critical Care: The Evolution of Cerebrovascular Critical Care. Crit Care Med 2021; 49:881-900. [PMID: 33653976 DOI: 10.1097/ccm.0000000000004933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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