Abstract
Background
With the increasing use of magnetic resonance imaging in the assessment of acute intracerebral hemorrhage, diffusion-weighted imaging hyperintense lesions have been recognized to occur at sites remote to the hematoma in up to 40% of patients. We investigated whether blood pressure reduction was associated with diffusion-weighted imaging hyperintense lesions in acute intracerebral hemorrhage and whether such lesions are associated with worse clinical outcomes by analyzing imaging data from a randomized trial.
Methods
We performed exploratory subgroup analyses in an open-label randomized trial that investigated acute blood pressure lowering in 1000 patients with intracerebral hemorrhage between May 2011 and September 2015. Eligible participants were assigned to an intensive systolic blood pressure target of 110–139 mm Hg versus 140–179 mm Hg with the use of intravenous nicardipine. Of these, 171 patients had requisite magnetic resonance imaging sequences for inclusion in these subgroup analyses. The primary outcome was the presence of diffusion-weighted imaging hyperintense lesions. Secondary outcomes included death or disability and serious adverse event at 90 days.
Results
Diffusion-weighted imaging hyperintense lesions were present in 25% of patients (mean age 62 years). Hematoma volume > 30 cm3 was an adjusted predictor (adjusted relative risk 2.41, 95% confidence interval 1.00–5.80) of lesion presence. Lesions occurred in 25% of intensively treated patients and 24% of standard treatment patients (relative risk 1.01, 95% confidence interval 0.71–1.43, p = 0.97). Patients with diffusion-weighted imaging hyperintense lesions had similar frequencies of death or disability at 90 days, compared with patients without lesions.
Conclusions
Randomized assignment to intensive acute blood pressure lowering did not result in a greater frequency of diffusion-weighted imaging hyperintense lesion. Alternative mechanisms of diffusion-weighted imaging hyperintense lesion formation other than hemodynamic fluctuations need to be explored.
Clinical trial registration ClinicalTrials.gov (Ref. NCT01176565; https://clinicaltrials.gov/ct2/show/NCT01176565).
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All authorship requirements have been met, and the final manuscript was approved by all authors. Study conception and design: AS, CC, AIQ, JR, JNG. Acquisition of data: AS, CC, AM, JR, JOF, FS, MJ, AA, AV, MRA, RHM. Administrative support: MJ, AA, AV, KS. Statistical analysis and interpretation of data: AS, CC, RHM, JR, JNG. Drafting of manuscript: AS. Critical revisions: AS, CC, AM, JR, JOF, FS, MJ, KB, LG, AA, AV, MRA, KS, MRA, RHM, AIQ, SMG, JR, JNG. Study supervision/funding: JNG, JR, AIQ.
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Supported by grants (National Institutes of Health - National Institute of Neurological Disorders and Stroke (NINDS) R01NS073344, to Dr. Rosand and U01-NS062091, to Dr. Qureshi). Chiesi USA and Astellas Pharma supplied intravenous nicardipine for use during the trial but had no other role in the design or conduct of the ATACH-2 trial or in this analysis/article. The National Institutes of Health, Chiesi USA, and Astellas Pharma had no involvement in the design, analyses, interpretation, or drafting of this report.
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The ATACH-2 protocol and consent forms were approved by the institutional review board or equivalent ethics committee at each participating site, and all participants or their legally authorized representative provided written informed consent.
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Shoamanesh, A., Cassarly, C., Morotti, A. et al. Intensive Blood Pressure Lowering and DWI Lesions in Intracerebral Hemorrhage: Exploratory Analysis of the ATACH-2 Randomized Trial. Neurocrit Care 36, 71–81 (2022). https://doi.org/10.1007/s12028-021-01254-9
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DOI: https://doi.org/10.1007/s12028-021-01254-9