Sebina Bulic, MD

Maximilian Oeinck M, Florian Neunhoeffer F, Klaus-Juergen Buttler KJ, Stephan Meckel S, Bernhard Schmidt B, Marek Czosnyka M, et al. Dynamic Cerebral Autoregulation in Acute Intracerebral Hemorrhage. Stroke. 2013

Pathophysiology of intracranial hemorrhage remains incompletely understood entity. Clinical management, including blood pressure management is still under debate. Cerebral autoregulation in ICH was previously studied, mainly in the steady state, and it was found that it was generally not impaired, however, if impaired soon after the ictus, than it was predictive of poor clinical outcomes.

In this study, Oeinck et al, aimed to investigate dynamic autoregulation during the acute stage of ICH and how it associates with clinical outcome. Over the 15 months, they followed 26 patients with ICH on days 1, 3 and 5, compared results with healthy individuals and recorded clinical outcomes.

They used TCD measurement of the MCA flow velocity in the function of the BP obtained via finger plethysmograph and calculated phase reflecting rapidity of autoregulation and gain reflecting damping characteristics. Pulsatility indices were calculated as well. All patients were provided standard of care in the NICU and by the physician blinded of acquired data. Various anti- hypertensive, potentially vasoreactive drugs, sedating medications, mechanical ventilation, EVD, stereotactic puncture and drainage and intraclot thrombolysis were used when indicated.

A correlation between low phase on day 5 and poor clinical outcome was established. It was also associated with large ICH volume and low GCS on day 1. Lower phase was also associated with lower blood pressure starting at mean ABP of 100mmHg. Gain was generally impaired, but was not associated with 90-day outcome.

Academically very interesting, these results, in particular association between lower phase and lower blood pressure, make me wait for further clinical trials (such as the ATACH II) results even more anxiously, to try to answer out blood pressure managing dilemma.