Andrea Morotti, MD
Elevated blood pressure has been consistently associated with active bleeding and unfavorable prognosis in acute intracerebral hemorrhage (ICH). Dr. Rodriguez-Luna and colleagues investigated whether systolic blood pressure (SBP) in the prehospital phase correlates with admission SBP and extent of bleeding measured as baseline ICH volume. To explore this association, a prospectively collected cohort of ICH patients was retrospectively analyzed. A total of 219 patients qualified for the analysis (mean age 76, 54% males), with mean baseline ICH volume of 25 mL. Prehospital SBP was strongly correlated with admission SBP (r=0.552; P<0.001) and baseline ICH volume (ρ=0.189; P=0.006), as shown in the Figure.
This association remained significant after adjustment for potential confounders in multivariable logistic regression. There was no association between prehospital SBP, and the frequency of the CT angiography spot sign, a robust and validated imaging marker of ICH expansion. Time from onset to baseline CT scan and ultra early hematoma growth were also not associated with prehospital SBP. As acknowledged by the authors, the main limitation of the study is the possibility that high levels of BP represent the consequence of larger hematoma volume and not the cause.
ICH expansion is a major cause of clinical deterioration and death in acute ICH. Hematoma growth occurs very early in the natural history of ICH, and, therefore, anti-expansion treatments should be administered as soon as possible.1 Two large randomized controlled trials, the INTERACT-2 and ATACH-2 studies,2,3 failed to consistently show that intensive blood pressure reduction reduces the odds of experiencing hematoma growth and improves outcome. Delayed initiation of blood pressure lowering may explain this observation because many subjects included in these trials were randomized after 3 hours from stroke onset.
Although obtained in a single-center, retrospective study with a relatively small sample size, the association between prehospital SBP and ICH volume is interesting and hypothesis-generating. Intensive BP lowering in the prehospital setting through mobile stroke units may reduce the time from ICH onset to anti-expansion treatment. Further studies are needed to test this hypothesis.
- Steiner T, Bösel J. Options to restrict hematoma expansion after spontaneous intracerebral hemorrhage. Stroke. 2010;41(2):402-409. doi:10.1161/STROKEAHA.109.552919.
- Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016. 15;375(11):1033-43. doi:10.1056/NEJMoa1603460.
- Anderson C, Heeley E, Huang Y, et al. Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage. N Engl J Med. 2013;368(25):2355-2365. doi:10.1056/NEJMoa1214609.