Medical Management of ICH

Is there any medical therapy which has been proven to benefit patients who suffer an ICH?

• Does treating hypertension in the acute period improve outcome?
  
  
• Is there any evidence that medical treatment of mass effect in patients with ICH improves outcome?

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Hypertension in ICH

Hypertension is very common after ICH.

MAP > 140 in 34%
MAP > 120 in 78%

Typically, blood pressure returns to baseline over the course of one week, with the greatest decline occurring during the first 24 hours.

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The Evidence

• Does lowering BP in acute period after ICH improve outcome?
  
• Does lowering of BP in acute period decrease changes of hematoma enlargement?

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Lowering Blood Pressure and Outcome

Study One
Meyer JS, Bauer RB. Medical treatment of spontaneous intracranial hemorrhage by use of hypotensive drugs. Neurology. 1962; 12: 36-47.

• 167 patients with ICH (diagnosed by clinical suspicion, LP, and angiography) were separated into treated and untreated group.
  
  • 123 patients treated with hypotensive drug (Reserpine IM)
  • 44 patients untreated
• Goal BP not stated, and degree of lowering variable.
  
• Typically Systolic BP brought to range of 160-180 mm Hg.
  
• Outcome: Mortality at 6 weeks.

Results: Overall mortality rate 81%

	# Patients	Mortality	Coma on Admission - #	Coma on Admission - %
Adequately Treated	40	63%	29/40	73%
Inadequately Treated	83	82%	65/83	78%
No treatment	44	98%	41/44	93%

 

Study Two
Dandapani BR, Suzuki S, Kelly RE, et al. Relation between blood pressure and outcome in intracerebral hemorrhage. Stroke. 1995. 26; 21-24.

• Retrospective chart review.
  
• Subjects: 87 patients with hypertensive ICH in thalamus or basal ganglia who had history of HTN.
  
• Analysis: Mortality and severe morbidity in patients with MAP > 125 mm Hg after treatment vs. MAP < 125 mm Hg after treatment at 6 hours.

Results:

	Mortality Rate (30d)	Mortality / Severe Morbidity (30 d)
MAP > 125	43%	60%
MAP < 125	21%	34%

Confounder:

	Treated MAP
	MAP < 125	MAP > 125
Initial MAP < 145	39 patients	14 patients
MAP MAP > 145	11 patients	23 patients

Rate of Blood Pressure Decline

Qureshi AI, Bliwise DL, Bliwise NG, et al. Rate of 24-hour blood pressure decline and mortality after spontaneous intracerebral hemorrhage: A retrospective analysis with a random effects regression model. Crit Care Med. 1999. 27(3): 480-485.

• Design: Retrospective Chart Review
  
• Inclusion Criteria: 105 patients with ICH who had more than 5 blood pressure measurements over the first 24 hours were included in the analysis.
  
• MAP calculated as a slope ( change mm Hg/hr)
  
• Determine effect of MAP Slope decline on mortality and functional outcome adjusted for GCS and hematoma volume.

Results:

• Rate decline patients who died -2.7 +2.1 mm Hg
  
• vs -1.2 + 1.1 mm Hg
  
• Logistic regression analysis showed that the rate of decline of BP in the first 24 hours an independent predictor of mortality but did not affect functional outcome of survivors.

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Hematoma Enlargement

Brott T, Broderick J, Kothari R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. 1997; 28: 1-5.

• 103 patients with ICH had CT done within 3 hours of onset. Repeat CT was done at 1 hour and 20 hours after baseline
  
• > 33% growth had occurred in 26% of patients between baseline and 1 hour CT scan
  
• > 33% growth had occurred in 40% of patients by 20 hour CT scan.

	> 33% growth	< 33% growth
Systolic BP at onset mm Hg	200 + 34	199 + 38
Diastolic BP at onset, mm Hg	110 + 18	108 + 28
History of HTN	62%	68%

Summary of Hypertension Treatment in Intracerebral Hemorrhage

Prospective	Retrospective	Case Series	Results
Meyer et al. 1962			Lower BP good
	Dandapani et al. 1995		Lower BP good
	Qureshi et al. 1999		Lower BP bad
		Brott T et al 1995	Hematoma enlargement not associated with degree of HTN

 

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The content of these pages was written by Dr. Aninda Acharya of St.Louis University.

Last Revised: August 31, 2002