Blood Pressure Management in Intracranial Hemorrhage: Current Challenges and Opportunities

Abstract

Non-traumatic intracranial hemorrhage (i.e. intracerebral hemorrhage [ICH] and subarachnoid hemorrhage [SAH]) are more life threatening and least treatable despite being less common than ischemic stroke. Elevated blood pressure (BP) is a strong predictor of poor outcome in both ICH and SAH. Data from a landmark clinical trial INTERACT 2, wherein 2839 participants enrolled with spontaneous ICH were randomly assigned to receive intensive (target systolic BP <140 mmHg) or guideline recommended BP lowering therapy (target systolic BP <180 mmHg), showed that intensive BP lowering was safe, and more favorable functional outcome and better overall health-related quality of life were seen in survivors in the intensive treatment group. These results contributed to the shift in European and American guidelines towards more aggressive early management of elevated BP in ICH. In contrast, the treatment of BP in SAH is less well defined and more complex. Although there is consensus that hypertension needs to be controlled to prevent rebleeding in the acute setting, induced hypertension in the later stages of SAH has questionable benefits.

Emerging concepts in sporadic cerebral amyloid angiopathy

“…They likely reflect repeated episodes of blood leaking into the subarachnoid space from brittle and fragile CAA affected vessels. Siderosis is emerging as perhaps the most clinically relevant manifestation of the disease: (i) it is a trigger of transient focal neurological symptoms ('amyloid spells') (Greenberg et al, 1993;Charidimou et al, 2012b), expanding the CAA clinical imaging spectrum (Raposo et al, 2011;Calviere et al, 2016); (ii) it has been shown to carry a very high risk of future symptomatic lobar ICH (Linn et al, 2010;Charidimou et al, 2013c) with important implications for CAA clinical care, such as strict blood pressure control (Gorelick et al, 2011;Biffi et al, 2015;Hemphill et al, 2015;Carcel et al, 2016) and avoiding antithrombotics unless otherwise strongly indicated (Biffi et al, 2010;Charidimou et al, 2012a); and (iii) it may be an independent risk factor for new onset dementia after ICH (Moulin et al, 2016). Of note, siderosis exerts these effects independent of, and above any effect of coincident microbleeds (Greenberg et al, 2004;Biffi et al, 2010).…”

Increased blood pressure variability predicts poor outcomes from endovascular treatment for aneurysmal subarachnoid hemorrhage

“…Despite the recommendation from the European Stroke Organization that SBP in SAH should be maintained below 180 mmHg in order to minimize the risk of rebleeding in managing ruptured aneurysms 19 , no optimal BP thresholds have yet been determined, given the absence of evidence from randomized clinical trials 20 . Moreover, there is also wide variability regarding BP management targeted on treatment of ruptured intracerebral aneurysms.…”