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Intro: Recent clinical trials suggest that intensive blood pressure lowering in acute intracerebral hemorrhage (ICH) does not result in a lower rate of death or disability. We aimed to compare the incidence of restricted diffusion and acute neurological deterioration in patients after an institutional protocol change in systolic blood pressure (SBP) target from <160 to <140 in all acute ICH regardless of time since onset.Hypothesis: Intensive blood pressure lowering in acute ICH increases chance of silent and symptomatic acute cerebral ischemia.Methods: We retrospectively compared persons with acute, primary ICH from 2013 to 2014 before and after a protocol change in SBP target from <160 to <140. Criteria included admission for acute ICH, MRI within 2 weeks from ICH, no emergent surgical evacuations, and death or withdrawal of care within the first 72 hours of admission. Patient characteristics, BP values, imaging, discharge data, neurological deterioration (not explained by hematoma expansion, seizures, or general medical condition) were collected. Groups were compared using chi-square test for categorical and Wilcoxon Rank Sum for numeric variables.Results: Of 286 primary ICH patients in the study period, 119 underwent MRI and met the study criteria (median age 72, interquartile range (IQR) 59-83, median ICH volume 5.7 cc, IQR 1.3-17.6), 62 patients with target SBP <160 (Group 1) and 57 patients in target SBP <140 (Group 2). There was no difference in frequency of MRI imaging between study periods. There were no significant differences between the 2 groups in age, initial NIH Stroke Scale, history of hypertension, hematoma volume, lobar ICH, time to MRI, or initial SBP (median 190 v 188; p=0.831). Mean SBP over the first 24 hours was lower in Group 2 (Group 1: 143 v Group 2: 134; p<0.001). In Group 1, 10 (16%) were found to have DWI changes compared with 18 (32%) of patients in Group 2 (p=0.047). Neurological deterioration increased from Group 1 to Group 2 (3% v 21%; p=0.003).Conclusions: Intensive lowering of SBP in acute ICH patients can result in increased cerebral ischemia on MRI and higher rates of neurological deterioration.