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

OBJECTIVE: To investigate whether intensive blood pressure treatment is associated with less hematoma growth and better outcome in ICH patients who received intravenous nicardipine treatment within 2 hrs 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 within 4.5 hours of symptom onset. 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 as compared with 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% 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 (OR, 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 within 2 hours of symptom onset, intensive blood pressure reduction was associated with reduced hematoma growth and improved functional outcome. This article is protected by copyright. All rights reserved.