Intracerebral haemorrhage

haematoma expansion

strongly a/w poor neuro outcome & mortality
- ↑ odds of dependence & death
rate of expansion highest in first 3h

Haemostatic therapy not used ∵ conflicting evidence on effect, safety, mortality

Current mainstay of treatment:

supportive care
reversal of anticoagulation
acute BP lowering
surgical evacuation reserved for more severe ICH

	When?	How much?	How long?
American Heart Association/American Stroke Association	Within 2 h of onset, ideally at target within 1 h Class 2a	SBP 140mmHg (range 130-150mmHg) in patients with mild-moderate ICH presenting with SBP 150-220mmHg Class 2b	No recommendation
European Stroke Organisation	As early as possible, ideally within 2 h Expert consensus	SBP 140mmHg (and above 110mmHg) if presenting within 6 h Weak recommendation	24–72 h Expert consensus
Chinese Stroke Association	No recommendation	SBP 140mmHg in patients with SBP > 150mmHg Class 2b	No recommendation
Australian Stroke Foundation	No recommendation	Less than 140mmHg, but not substantially lower Weak recommendation	No recommendation

Large systolic blood pressure drops should be avoided, as shown in a pooled analysis of patients from the INTERACT2 and ATACH-2 trials (predominantly mild-to-moderate severity I, where systolic blood pressure drops of >60mmHg within the first hour were found to be harmful

Hypotension (i.e. a systolic blood pressure of less than 100mmHg) is avoided in clinical practice, and on presentation with ICH has been shown to be associated with poor outcome

One concern of aggressive blood pressure lowering is secondary ischaemic injury, which can manifest as remote ischaemic lesions in acute ICH. However, the post hoc analysis of ATACH-2 and a large observational study (Ethnic/Racial Variations of Intracerebral Hemorrhage, ERICH) did not demonstrate an association with intensive blood pressure lowering and risk of new ischaemic injury

Systolic blood pressure variability has been shown to be associated with poor functional outcomes in ICH, and it has been suggested that sustained control, with avoidance of peaks, may enhance the benefits of blood pressure reduction

The effect on haematoma expansion and functional outcomes in ICH when targeting diastolic blood pressure and mean arterial blood pressure are not well explored in the literature
Given this, there are no recommendations relating to diastolic or mean arterial pressure targets in the guidelines.

The optimal length of acute blood pressure intervention in ICH is not known, relating to the paucity of high-quality data. The length of intervention in INTERACT2 and INTERACT3 was 7 days, and 24 h in ATACH-2. Given this, only the European Stroke Organisation guidelines comment on length of acute blood pressure management (24–72 h) which was an expert consensus decision

All large trials recruited patients within 4.5–6 h from their symptom onset, and therefore aggressive blood pressure lowering with intravenous agents in patients presenting after 24 h from symptom onset is likely of limited benefit

Which agents

Route
- 1st 24h : usually IV
- → then switched to PO
Agents
- IV nicardipine usually 1st line
  - dihydropyridine CCB
  - rapidly titratable
  - safe, limited ADR
- hydralazine
  - reflex tachycardia
  - tachyphylaxis
- labetalol
  - bradyarrhythmia
  - bronchospasm
- avoid GTN
  - transdermal GTN a/w harm in RIGHT-2 & MR ASAP trials
  - ∵ ↓ protective vasoconstriction to prevent haematoma expansion

A cohort study investigated the use of intravenous hydralazine, labetalol and nicardipine, and found agent used was associated with only initial reduction in diastolic but not systolic BP, and there were no differences in subsequent clinical outcomes

Bundle care

↓BP
reversal of anticoagulation
correct hyperglycaemia
correct pyrexia

References

Blood Pressure Management in Intracerebral Haemorrhage When, How Much, and for How Long