Koch Sebastian, Romano Jose G, Forteza Alejandro M, Otero Carolina Mejia, Rabinstein Alejandro A
Department of Neurology, University of Miami Miller School of Medicine, 1150 NW 14th Street, Suite 609, Miami, FL 33136, USA.
Neurocrit Care. 2008;8(3):316-21. doi: 10.1007/s12028-008-9085-8.
The optimal blood pressure (BP) for treating acute intracerebral hemorrhage remains (ICH) uncertain. High BP may contribute to hematoma growth while excessive BP reduction might precipitate peri-hemorrhage ischemia. We examine here the feasibility and safety of reducing BP to lower than presently recommended levels in patients with acute ICH.
Patients with ICH were prospectively randomized to standard BP treatment (mean arterial BP [MAP] 110-130 mmHg) or aggressive BP lowering (MAP < 110 mmHg) within 8 h of symptom onset. MAP was managed during the 48 h treatment period. NIHSS was obtained at baseline, 24, and 48 h. Brain CT was done 24 h after symptoms. A modified Rankin Scale (mRs) was obtained at 90 days. A clinical decline (NIHSS drop > or = 2 points) within the first 48 h was the primary endpoint. Hematoma enlargement at 24 h was a secondary endpoint.
We enrolled 21 patients into each group. Mean age was 60.6 +/- 12.3 years and MAP on presentation was 147.6 +/- 18.2 mmHg. Treatment was started on average 3.2 +/- 2.2 h after symptom onset. Baseline clinical variables were identical between the 2 treatment groups. Target blood pressure was achieved within 87.1 +/- 59.6 min in the standard group and 163.5 +/- 163.8 min in the aggressive BP treatment group. There were no significant differences in early neurological deterioration, hematoma and edema growth, and clinical outcome at 90 days.
A more aggressive reduction of acute hypertension after ICH does not increase the rate of neurological deterioration even when treatment is initiated within hours of symptom onset. Lowering BP aggressively did not affect hematoma and edema expansion but this possibility deserves further study.
治疗急性脑出血（ICH）的最佳血压仍不确定。高血压可能导致血肿增大，而过度降低血压可能会引发出血周围缺血。我们在此研究将急性ICH患者的血压降至低于目前推荐水平的可行性和安全性。
ICH患者在症状出现后8小时内被前瞻性随机分为标准血压治疗组（平均动脉压[MAP] 110 - 130 mmHg）或积极降压组（MAP < 110 mmHg）。在48小时治疗期间管理MAP。在基线、24小时和48小时时获取美国国立卫生研究院卒中量表（NIHSS）评分。症状出现后24小时进行脑部CT检查。在90天时获取改良Rankin量表（mRs）评分。前48小时内临床恶化（NIHSS评分下降≥2分）是主要终点。24小时时血肿扩大是次要终点。
每组纳入21例患者。平均年龄为60.6±12.3岁，就诊时MAP为147.6±18.2 mmHg。平均在症状出现后3.2±2.2小时开始治疗。两个治疗组的基线临床变量相同。标准组在87.1±59.6分钟内达到目标血压，积极降压治疗组在163.5±163.8分钟内达到目标血压。早期神经功能恶化、血肿和水肿增长以及90天时的临床结局无显著差异。
即使在症状出现数小时内开始治疗，ICH后更积极地降低急性高血压也不会增加神经功能恶化的发生率。积极降低血压并未影响血肿和水肿扩大，但这种可能性值得进一步研究。
