Mark N Rubin, MD

Gould B, McCourt R, Gioia RC, Kate M, Hill MD, Asdaghi N, et al. Acute Blood Pressure Reduction in Patients With Intracerebral Hemorrhage Does Not Result in Borderzone Region Hypoperfusion. Stroke. 2014

“’Is there no way,’ said I, ‘of escaping Charybdis, and at the same time keeping Scylla off when she is trying to harm my men?
 “’…Neptune himself could not save you [from Charybdis]; you must hug the Scylla side and drive ship by as fast as you can, for you had better lose six men than your whole crew.’”
–          Odysseus & Circe, Book XII, The Odyssey, Homer, circa 800 B.C.E.

Intracerebral hemorrhage, as previously discussed, is bad disease. Patients are rather unwell in the acute setting, are susceptible to a host of complications during their prolonged recovery, and frequently have a poor long-term outcome.

One of the myriad concerns in the acute setting is blood pressure management. Systemic blood pressure is typically through the roof when we meet patients with intracranial hemorrhage, and systolic blood pressure >200 mmHg – frequently achieved in this cohort – is an independent predictor of hematoma expansion (and, thereby, worsening neurologic injury). On the other hand, some have noted diffusion-weighted MRI changes in the perihematoma region, suggesting this may represent a region of hypoperfusion after intracerebral hemorrhage. Thus, the suggestion is we must navigate between Scylla and Charybdis: the importance of keeping blood pressure below an unclear threshold must be balanced by the potential injury from overly aggressive antihypertensive therapy, or so the controversy stated.

The ICH ADAPT investigators, however, have contributed an important piece of information to this discussion. The trial, which tested the hypothesis that cerebral blood flow (as measured by multiparametric CT) is not significantly affected by antihypertensive treatment, demonstrated that mean blood flow is not significantly affected by aggressive antihypertensive treatment. This more recent contribution, a subanalysis, focused on whether or not aggressive blood pressure reduction was more likely to tip individual patients into an ischemic threshold; a subgroup that may have escaped the original analysis. In brief, their sophisticated cerebral blood flow analysis did not suggest that those aggressively treated were any more likely to have regions of ischemia around their hematoma or arterial borderzone regions, at least at 2 hours after their original assessment.

The authors appropriately list the limitations of this study, namely that they only see a very early point in time and that there was substantial heterogeneity in patients and scanners, but this is still an important contribution. This is one more piece of evidence to suggest that the supposed controversy of blood pressure reduction (Scylla) vs hypoperfusion (Charybdis) is perhaps overstated and that Circe’s advice still stands: hug the Scylla side.