Rajbeer Singh Sangha, MD

Chan E, Anderson CS, Wang X, Arima H, Saxena A, Moullaali TJ, et al. Significance of Intraventricular Hemorrhage in Acute Intracerebral Hemorrhage:Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial Results. Stroke. 2015

Brain hemorrhage can be devastating and lead to the highest morbidity and mortality of any stroke subtype. About 33% to 45% of spontaneous ICHs and 25% of aneurysmal SAHs extend into the ventricles. Patients with IVH are twice as likely to have poor outcomes (a modified Rankin scale [mRS] score of 4–6 at hospital discharge) and nearly three times more likely to die than their cohorts without IVH.1 The authors of this study analyzed risk associations of IVH and outcomes among participants of the main phase Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) study. 

The INTERACT2 study was an international, multicenter, open, blinded endpoint, randomized controlled trial. The study enrolled 2839 patients with CT-confirmed spontaneous ICH within 6 hours of onset and elevated systolic BP (SBP, 150-220 mmHg) were randomly assigned to receive intensive (target SBP <180 mmHg). Patient characteristics that pointed towards a greater probability of IVH included older age and with greater neurological impairment, having a previous history of ischemic stroke, and having larger hematomas at presentation that were located in the deep hemisphere. Death or major disability occurred in 66% with IVH versus 49% in ICH-alone patients (adjusted odds ratio 1.68, 95% confidence interval 1.38-2.06; p<0.01).

Associations of IVH volume and clinical outcomes were strong, showing thresholds of approximately 5 and 10mL for significantly increased odds of death, and or major disability. This threshold should be recognized by clinicians and may prompt more aggressive therapy or intervention going further in the future. This analysis may be further confirmed by the results of the ongoing CLEAR III trial which hopefully gives us a positive result.

1. Hallevi H, Albright KC, Aronowski J, et al. Intraventricular hemorrhage: anatomic relationships and clinical implications. Neurology. 2008;70(11):848–852