Blood Pressure and Outcomes in Patients With Different Etiologies of Intracerebral Hemorrhage: A Multicenter Cohort Study

Abstract

Background We aimed to investigate the association between blood pressure (BP) and outcomes in intracerebral hemorrhage (ICH) subtypes with different etiologies. Methods and Results A total of 5656 in‐hospital patients with spontaneous ICH were included between January 2012 and December 2016 in a prospective multicenter cohort study. Etiological subtypes of ICH were assigned using SMASH‐U (structural lesion, medication, amyloid angiopathy, systemic/other disease, hypertension, undetermined) classification. Elevated systolic BP was defined as ≥140 mm Hg. Hypertension was defined as elevated BP for >1 month before the onset of ICH. The primary outcomes were measured as 1‐month survival rate and 3‐month mortality. A total of 5380 patients with ICH were analyzed, of whom 4052 (75.3%) had elevated systolic BP on admission and 3015 (56.0%) had hypertension. In multinomial analysis of patients who passed away by 3 months, systolic BP on admission was significantly different in cerebral amyloid angiopathy ( P <0.001), structural lesion ( P <0.001), and undetermined subtypes ( P =0.003), compared with the hypertensive angiopathy subtype. Elevated systolic BP was dose‐responsively associated with higher 3‐month mortality in hypertensive angiopathy ( P trend =0.013) and undetermined ( P trend =0.005) subtypes. In cerebral amyloid angiopathy, hypertension history had significant inverse association with 3‐month mortality (adjusted odds ratio, 0.37, 95% CI, 0.20–0.65; P <0.001). Similarly, adjusted Cox regression indicated decreased risk of 1‐month survival rate in the presence of hypertension in patients with cerebral amyloid angiopathy (adjusted hazard ratio, 0.47; 95% CI, 0.24–0.92; P =0.027). Conclusions This study suggests that the association between BP and ICH outcomes might specifically depend on its subtypes, and cerebral amyloid angiopathy might be pathologically distinctive from the others. Future studies of individualized BP‐lowering strategy are needed to validate our findings.

Impact of Non-pharmacological Chronic Hypertension on a Transgenic Rat Model of Cerebral Amyloid Angiopathy

“…On the other hand, mixed ICH patients seemed to have a higher incidence of ICH than only HTN ICH occurrences ( Pasi et al, 2018 ) suggesting a possible protective effect of HTN in CAA. Another study reported similar results; CAA patients with HTN had better clinical outcomes after ICH events ( Zhang et al, 2020 ). Treating with anti-hypertensive therapies was shown to reduce incidence of ICH and stroke in HTN patients ( Qureshi et al, 2001 ) and was also found to decrease ICH incidence in CAA patients ( Arima et al, 2010 ).…”

Therapeutic drug level of tacrolimus causing intracranial hemorrhage in a patient with renal transplant

“…However, arteriography and venography study showed normal arterial and venous walls. Amyloid angiopathy commonly occurs in old age and in a patient with high blood pressure 8 . However, there was no evidence of amyloid deposition on MRI.…”

“…Amyloid angiopathy commonly occurs in old age and in a patient with high blood pressure. 8 However, there was no evidence of amyloid deposition on MRI. Neoplastic tissues are hypervascular, and blood vessels are usually fragile that can undergo necrosis, and put the patients at risk of intracerebral bleeding.…”

Updated Outlook of Cerebral Amyloid Angiopathy and Inflammatory Subtypes: Pathophysiology, Clinical Manifestations, Diagnosis and Management

“…Blood pressure management is deemed critical to prevent hematoma expansion and blood pressure monitoring with systemic arterial pressure should be considered. American Heart Association recommends lowering systolic blood pressures in the setting of acute ICH to 140 is safe while maintaining mean arterial pressures greater than 65 [ 56 ]. Furthermore, critical care management in the emergency department should include monitoring for any change in the neurological examination.…”