Intracranial Hemorrhage Patients Better Off After Having Blood Pressure Lowered Even More

An article in The Lancet Neurology suggests that in individuals who have had intracranial hemorrhage, hematoma growth can be reduced by lowering their blood pressure even further than what existing guidelines recommend.

A patient’s blood pressure can rapidly increase due to intracranial hemorrhage (bleeding within the skull). This condition often leads to further hemorrhage and the growth of an area of internal bleeding (hematoma) that worsens the patient’s condition. Due to increased pressure on important brain structures, the condition also increases the risk of early death or residual disability. It is common practice to quickly lower very high blood pressure after a hemorrhage, but there is still some debate about exactly when to begin the treatment and how much to lower blood pressure. In clinical situations around the world, there is considerable variation in high blood pressure management.

To compare standard treatment strategy with a more intensive one, Dr Craig Anderson (The George Institute for International Health, Sydney, Australia) and colleagues designed a randomized pilot trial with participating hospitals in Australia, China and South Korea between November 2005 and August 2007. One group of patients (203 individuals) received an intensive blood-pressure-lowering strategy, targeting systolic blood pressure at 140 mm Hg. A second group (201 individuals) received the recommended best practice standard strategy, targeting systolic blood pressure at 180 mm Hg. All patients had spontaneous intracerebral hemorrhage.

In order to be included in the trial, doctors confirmed each participant’s diagnosis using a CT (computerized tomography). Twenty-four hours after treatment, patients received another CT scan to check for hematoma growth. Hematoma growth in the intensive treatment group was significantly lower than in the standard treatment group: 13.7% vs. 36.3%, respectively. In addition, there were no significant differences in the numbers of adverse side-effects or in any of the secondary clinical outcomes – number of deaths, degrees of disability, physical and mental functioning, and quality of life in survivors 90 days after treatment.

“Because intravenous treatment to lower blood pressure is relatively straightforward, is not hazardous, and is of low cost, if applied widely these effects could translate into major absolute benefits,” conclude the researchers.

An accompanying Comment, written by Dr Mustapha Ezzeddine (University of Minnesota, Minneapolis, USA) notes: “The INTERACT trial represents the best evidence to date of the safety of such an intervention”. He adds that although many questions – such as whether these results are generalisable to other stroke patients and how long blood pressure needs to be controlled for – remain unanswered, the follow-up studies of INTERACT, and a related trial ATACH2, “will be able to answer some of these questions, but more importantly, detect any impact on outcomes”.

Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial
Craig S Anderson, Yining Huang, Ji Guang Wang, Hisatomi Arima, Bruce Neal, Bin Peng, Emma Heeley, Christian Skulina, Mark W Parsons, Jong Sung Kim, Qing Ling Tao, Yue Chun Li, Jian Dong Jiang, Li Wen Tai, Jin Li Zhang, En Xu, Yan Cheng, Stephane Heritier, Lewis B Morgenstern, John Chalmers.
The Lancet Neurology. April 5, 2008.

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Written by: Peter M Crosta