521: CEREBRAL ISCHEMIA AND OUTCOMES WITH RAPID BLOOD PRESSURE LOWERING IN INTRACEREBRAL HEMORRHAGE

Abstract

Introduction: Guidelines support acute systolic blood pressure (SBP) lowering in intracerebral hemorrhage (ICH) if SBP is between 150 and 220 mmHg to improve outcomes. Recommendations for SBP >220 mm Hg are less clear. A proposed risk is failure of cerebral autoregulation, leading to brain ischemia and poor outcomes. Methods: A single center, retrospective cohort study of adult ICH patients from July 2017 to 2021. Patients from outside of the hospital system, in-hospital ICH, pregnant, or a prisoner were excluded. The primary outcome was incidence of cerebral ischemia in patients with SBP >220 mmHg (high) vs. 150-219 mmHg (low), assessed through percent SBP lowering and evaluation of radiographic imaging during admission. Secondary outcomes included poor neurologic status with mRS of 4 to 6 at discharge. Results: Of the 393 patients included, median (IQR) premorbid mRS was 0 in both groups, median (IQR) NIHSS was high; 16 (8, 23) vs. low; 13 (5, 19), p < 0.01. The median (IQR) presenting SBP was high; 236 (225, 246) mmHg vs. low; 180 (166, 197) mmHg. SBP goal was achieved in the first 24 hours in high; 86% vs. low; 77%, p = 0.09. Median (IQR) change in SBP 12 hours after arrival was high; -98 (-112, -83) mmHg vs. low; -47 (-62, -25) mmHg (p < 0.01) with a percent change in 12 hour SBP of 41% vs. 25%, p < 0.01. Significance persisted at 18 and 24 hours after arrival. Both groups had a mean (SD) of 7 (4) radiographic images obtained during admission. The median (IQR) time to detection of ischemia was high; 2.8 (1.4, 5.7) days vs. low; 3.1 (1.2, 6.6) days, p = 0.6. Presence of ischemic insults did not differ in the regression model based on presenting SBP groups [HR 0.57 (0.25, 1.3) p = 0.81] or percent change in SBP > or < 25% at 24 hours [HR 0.83 (0.41, 1.69) p = 0.61]. Poor neurologic outcome at discharge was present in high; 82% vs. low; 69% of patients (p = 0.07). Higher admission ICH score (p < 0.01) and NIHSS (p < 0.01) was associated with a poor outcome in the regression model. Conclusions: These results suggest there was no difference in the development of ischemic changes based on presenting SBP or percent change in the SBP. Poor neurologic outcome was associated with higher NIHSS and ICH score on admission in the analysis. These results will need to be confirmed in a randomized study.