Hyperacute Intracerebral Hemorrhage Research Articles

Emergent Management of Intracerebral Hemorrhage.

Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH. Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques. This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.

International beliefs and head positioning practices in patients with spontaneous hyperacute intracerebral hemorrhage

Prior to the conduct of the Head Position in Stroke Trial (HeadPoST), an international survey (n = 128) revealed equipoise for selection of head position in acute ischemic stroke. We aimed to determine whether equipoise exists for head position in spontaneous hyperacute intracerebral hemorrhage (ICH) patients following HeadPoST. This is an international, web-distributed survey focused on head positioning in hyperacute ICH patients. A survey was constructed to examine clinicians' beliefs and practices associated with head positioning of hyperacute ICH patients. Survey items were developed with content experts, piloted, and then refined before distributing through stroke listservs, social media, and purposive snowball sampling. Data were analyzed using descriptive statistics and χ2 test. We received 181 responses representing 13 countries on four continents: 38% advanced practice providers, 32% bedside nurses, and 30% physicians; overall, participants had median 7 [interquartile range (IQR) = 3-12] years stroke experience with a median of 100 (IQR = 37.5-200) ICH admissions managed annually. Participants disagreed that HeadPoST provided 'definitive evidence' for head position in ICH and agreed that their 'written admission orders include 30-degree head positioning', with 54% citing hospital policies for this head position in hyperacute ICH. Participants were unsure whether head positioning alone could influence ICH longitudinal outcomes. Use of serial proximal clinical and technology measures during the head positioning intervention were identified by 82% as the most appropriate endpoints for future ICH head positioning trials. Interdisciplinary providers remain unconvinced by HeadPoST results that head position does not matter in hyperacute ICH. Future trials examining the proximal effects of head positioning on clinical stability in hyperacute ICH are warranted.

S-06-3: EMERGENT BLOOD PRESSURE LOWERING WITH INTRAVENOUS NICARDIPINE FOR JAPANESE PATIENTS WITH ACUTE INTRACEREBRAL HEMORRHAGE: AN INDIVIDUAL PARTICIPANT DATA ANALYSIS

Objective: Intensive lowering of elevated blood pressure is one of the few promising therapies for acute intracerebral hemorrhage. The effects of acute systolic blood pressure levels achieved with intravenous nicardipine for Japanese patients with acute intracerebral hemorrhage on clinical outcomes were determined. Design and method: A systematic review and individual participant data analysis of articles before October 1, 2020 identified on PubMed were performed (PROSPERO: CRD42020213857). Prospective studies involving adults developing hyperacute intracerebral hemorrhage who were treated with intravenous nicardipine whose outcome was assessed using the modified Rankin Scale were eligible. Outcomes included death or disability at 90 days, defined as the modified Rankin Scale score of 4–6, and hematoma expansion, defined as an increase 6 mL or more from baseline to 24-h computed tomography. In this study, data on Japanese patients were extracted. The study is registered with PROSPERO (CRD42020213857). Results: Three studies, ATACH-1, ATACH-2, and SAMURAI-ICH, met the eligibility criteria. Of 1,271 patients enrolled, 500 were registered from Japan, and all of these were Japanese. A patient with available data on the hourly blood pressures only for < 4 timepoints was excluded, and the other 449 patients (age 64.9 ± 11.8 years, 183 women, initial BP 203.5v± 18.3 / 109.1 ± 17.2 mmHg) were studied. Death or disability occurred in 35.6%, and hematoma expansion occurred in 15.6%. Mean hourly systolic blood pressure during the initial 24 h was positively associated with death or disability (adjusted odds ratio 1.26, 95% confidence interval 1.04–1.53 per 10 mmHg) and hematoma expansion (1.47, 1.17–1.85). These odds ratios were relatively high as compared to the reported ones for global patients of this individual participant data analysis [1.12 (95% confidence interval 1.00–1.26) and 1.16 (1.02–1.32), respectively] (Toyoda K, et al: Int J Stroke 2021). Conclusions: Rapid lowering of systolic blood pressure by continuous administration of intravenous nicardipine during the initial 24 h was associated with lower risks of hematoma expansion and 90-day death or disability in Japanese patients with hyperacute intracerebral hemorrhage. The impact of systolic blood pressure lowering on better outcome seemed to be stronger in Japanese patients than the global ones.

Intravenous nicardipine for Japanese patients with acute intracerebral hemorrhage: an individual participant data analysis

The effects of acute systolic blood pressure levels achieved with continuous intravenous administration of nicardipine for Japanese patients with acute intracerebral hemorrhage on clinical outcomes were determined. A systematic review and individual participant data analysis of articles were performed based on prospective studies involving adults developing hyperacute intracerebral hemorrhage who were treated with intravenous nicardipine. Outcomes included death or disability at 90 days, defined as the modified Rankin Scale score of 4–6, and hematoma expansion, defined as an increase 6 mL or more from baseline to 24 h computed tomography. Of the total 499 Japanese patients (age 64.9 ± 11.8 years, 183 women, initial BP 203.5 ± 18.3/109.1 ± 17.2 mmHg) studied, death or disability occurred in 35.6%, and hematoma expansion occurred in 15.6%. Mean hourly systolic blood pressure during the initial 24 h was positively associated with death or disability (adjusted odds ratio 1.25, 95% confidence interval 1.03–1.52 per 10 mmHg) and hematoma expansion (1.49, 1.18–1.87). These odds ratios were relatively high as compared to the reported ones for overall global patients of this individual participant data analysis [1.12 (95% confidence interval 1.00–1.26) and 1.16 (1.02–1.32), respectively]. In conclusion, lower levels of systolic blood pressure by continuous intravenous nicardipine were associated with lower risks of hematoma expansion and 90-day death or disability in Japanese patients with hyperacute intracerebral hemorrhage. The impact of systolic blood pressure lowering on better outcome seemed to be stronger in Japanese patients than the global ones.

Intensive blood pressure lowering with nicardipine and outcomes after intracerebral hemorrhage: An individual participant data systematic review.

Nicardipine has strong, rapidly acting antihypertensive activity. The effects of acute systolic blood pressure levels achieved with intravenous nicardipine after onset of intracerebral hemorrhage on clinical outcomes were determined. A systematic review and individual participant data analysis of articles before 1 October 2020 identified on PubMed were performed (PROSPERO: CRD42020213857). Prospective studies involving hyperacute intracerebral hemorrhage adults treated with intravenous nicardipine whose outcome was assessed using the modified Rankin Scale were eligible. Outcomes included death or disability at 90 days, defined as the modified Rankin Scale score of 4-6, and hematoma expansion, defined as an increase ≥6 mL from baseline to 24-h computed tomography. Three studies met the eligibility criteria. For 1265 patients enrolled (age 62.6 ± 13.0 years, 484 women), death or disability occurred in 38.2% and hematoma expansion occurred in 17.4%. Mean hourly systolic blood pressure during the initial 24 h was positively associated with death or disability (adjusted odds ratio (aOR) 1.12, 95% confidence interval (CI) 1.00-1.26 per 10 mmHg) and hematoma expansion (1.16, 1.02-1.32). Mean hourly systolic blood pressure from 1 h to any timepoint during the initial 24 h was positively associated with death or disability. Later achievement of systolic blood pressure to ≤140 mmHg increased the risk of death or disability (aOR 1.02, 95% CI 1.00-1.05 per hour). Rapid lowering of systolic blood pressure by continuous administration of intravenous nicardipine during the initial 24 h in hyperacute intracerebral hemorrhage was associated with lower risks of hematoma expansion and 90-day death or disability without increasing serious adverse events.

Regional Differences in the Response to Acute Blood Pressure Lowering After Cerebral Hemorrhage.

ObjectiveTo compare the impact of intensive blood pressure (BP) lowering right after intracerebral hemorrhage (ICH) on clinical and hematoma outcomes among patients from different geographic locations, we performed a prespecified subanalysis of a randomized, multinational, 2-group, open-label trial to determine the efficacy of rapidly lowering BP in hyperacute ICH (Antihypertensive Treatment of Acute Cerebral Hemorrhage [ATACH]-2), involving 537 patients from East Asia and 463 recruited outside of Asia.MethodsEligible patients were randomly assigned to a systolic BP target of 110 to 139 mm Hg (intensive treatment) or 140 to 179 mm Hg (standard treatment). Predefined outcomes were poor functional outcome (modified Rankin Scale score 4–6 at 90 days), death within 90 days, hematoma expansion at 24 hours, and cardiorenal adverse events within 7 days.ResultsPoor functional outcomes (32.0% vs 45.9%), death (1.9% vs 13.3%), and cardiorenal adverse events (3.9% vs 11.2%) occurred significantly less frequently in patients from Asia than those outside of Asia. The treatment-by-cohort interaction was not significant for any outcomes. Only patients from Asia showed a lower incidence of hematoma expansion with intensive treatment (adjusted relative risk [RR] 0.56, 95% confidence interval [CI] 0.38–0.83). Both Asian (RR 3.53, 95% CI 1.28–9.64) and non-Asian (RR 1.71, 95% CI 1.00–2.93) cohorts showed a higher incidence of cardiorenal adverse events with intensive treatment.ConclusionsPoor functional outcomes and death 90 days after ICH were less common in patients from East Asia than those outside of Asia. Hematoma expansion, a potential predictor for poor clinical outcome, was attenuated by intensive BP lowering only in the Asian cohort.ClinicalTrials.gov IdentifierNCT01176565.Classification of EvidenceThis study provides Class II evidence that, for patients from East Asia with ICH, intensive blood pressure lowering significantly reduces the risk of hematoma expansion.

Inhibition of astrocytic activity alleviates sequela in acute stages of intracerebral hemorrhage.

Neurological deterioration of intracerebral hemorrhage (ICH) mostly occurs within the first 24 hours. Together with the microglia/macrophages (MMΦ), astrocytes are important cell population responsible for many brain injuries but rarely being highlighted in acute stage of ICH. In present study, we induced rats ICH either by collagenase or autologous blood injection. Experimental groups were classified as vehicle or Ethyl-1-(4-(2,3,3-trichloroacrylamide)phenyl)-5-(trifluoromethyl)-1H-pyrazole-4-carboxylate (Pyr3) treatment group (n = 9, each group). MRI assessments after ICH were used to evaluate the hematoma progression and blood–brain barrier (BBB) integrity. The glia cells accumulations were examined by GFAP and Iba1 immunohistochemistry, respectively. Abundant astrocytes but few MMΦ were observed in hyperacute and acute ICH. Upon suppression of astrocyte activity, ICH rats exhibited decreased size of hematoma expansion, less BBB destruction, reduced astrocyte accumulation in perihematomal regions, postponed course of hemoresolution and gain better outcomes. These finding provide evidence that activated astrocytes are crucial cell populations in hyperacute and acute ICH, and their modulation may offer opportunities for novel therapy and patient management.

The PRE-hospital Stroke Treatment Organization.

Background The PRE-hospital Stroke Treatment Organization was formed in 2016 as an international consortium of medical practitioners involved in pre-hospital treatment of patients with acute stroke. Aims PRE-hospital Stroke Treatment Organization's mission is to improve stroke outcomes by supporting research and advocacy for pre-hospital stroke treatment in Mobile Stroke Units. PRE-hospital Stroke Treatment Organization will provide a platform to enhance collaborative research across the spectrum of acute stroke management in the pre-hospital setting. PRE-hospital Stroke Treatment Organization will also facilitate the appropriate proliferation and distribution of Mobile Stroke Units by providing a forum for professional communication, resource for public education, and stimulus for government, industry, and philanthropic support. Summary of review In this "white paper", we describe the evidence supporting pre-hospital stroke treatment, progress to date, practical issues such as application in various environments and staffing, planned research initiatives, and organizational structure. Conclusions PRE-hospital Stroke Treatment Organization is not-for-profit, with membership open to anyone involved (or hoping to become involved) in pre-hospital stroke care. PRE-hospital Stroke Treatment Organization has a Steering Committee comprised of members from Europe, U.S., Canada, Australia, and other regions having a Mobile Stroke Unit in operation. PRE-hospital Stroke Treatment Organization convenes satellite meetings for membership at the International Stroke Conference and European Stroke Congress each year to address the PRE-hospital Stroke Treatment Organization mission. The first research collaborations agreed upon are to: (1) develop a list of common data elements to be collected by all Mobile Stroke Unit programs and entered into a common research database, and (2) develop a protocol for investigating the natural history of hyper-acute Intracerebral Hemorrhage.

Relative systolic blood pressure reduction and clinical outcomes in hyperacute intracerebral hemorrhage: the SAMURAI-ICH observational study.

Blood pressure lowering is often performed as a part of general acute management in acute intracerebral hemorrhage (ICH) patients. The relationship between relative blood pressure reduction and clinical outcomes is not fully known. Hyperacute (<3 h from onset) ICH patients with initial SBP more than 180 mmHg were included in the observational study. All patients received intravenous antihypertensive treatment based on a predefined protocol to lower and maintain SBP between 120 and 160 mmHg. The relative SBP reduction was defined as the ratio of SBP reduction to the admission SBP in the first 24 h, and associations between the relative SBP reduction and neurological deterioration (≥2 points decrease in the Glasgow Coma Scale score or ≥4 increase in the National Institutes of Health Stroke Scale score), hematoma expansion (>33% increase), and unfavorable outcome (modified Rankin scale score 4-6 at 3 months) were assessed with multivariate logistic regression analyses. Of the 211 patients [81 women, median age 65 (interquartile range 58-74) years, and median initial National Institutes of Health Stroke Scale score 13 (8-17)] enrolled, 17 (8%) showed neurological deterioration, 36 (17%) showed hematoma expansion, and 87 (41%) had an unfavorable outcome. On multivariate regression analyses, relative SBP reduction was independently and inversely associated with neurological deterioration (odds ratio 0.053, 95% confidence interval 0.011-0.254 per 10% increment), hematoma expansion (0.289, 0.099-0.841), and unfavorable outcome (0.254, 0.095-0.680) after adjusting for known predictive factors. Insufficient relative SBP reduction after standardized antihypertensive therapy in hyperacute ICH was independently associated with poor clinical outcomes. Aggressive antihypertensive treatment may improve clinical outcomes.

Simultaneous detection and separation of hyperacute intracerebral hemorrhage and cerebral ischemia using amide proton transfer MRI.

To explore the capability of amide proton transfer (APT) imaging in the detection of hemorrhagic and ischemic strokes using preclinical rat models. The rat intracerebral hemorrhage (ICH) model (n = 10) was induced by injecting bacterial collagenase VII-S into the caudate nucleus, and the permanent ischemic stroke model (n = 10) was induced by using a 4-0 nylon suture to occlude the origin of the middle cerebral artery. APT-weighted (APTw) MRI was acquired on a 4.7T animal imager and quantified using the magnetization transfer-ratio asymmetry at 3.5 ppm from water. There was a consistently high APTw MRI signal in hyperacute ICH during the initial 12 h after injection of collagenase compared with the contralateral brain tissue. When hemorrhagic and ischemic stroke were compared, hyperacute ICH and cerebral ischemia demonstrated opposite APTw MRI contrasts-namely, hyperintense versus hypointense compared with contralateral brain tissue, respectively. There was a stark contrast in APTw signal intensity between these two lesions. APT-MRI could accurately detect hyperacute ICH and distinctly differentiate hyperacute ICH from cerebral ischemia, thus opening up the possibility of introducing to the clinic a single MRI scan for the simultaneous visualization and separation of hemorrhagic and ischemic strokes at the hyperacute stage. Magn Reson Med 74:42-50, 2015. © 2014 Wiley Periodicals, Inc.

Abstract T P311: Lipid Profile and Clinical Outcomes in Acute Intracerebral Hemorrhage: The SAMURAI-ICH Study

Background and purpose: Although low serum total cholesterol (TC) levels are associated with an increased risk of intracerebral hemorrhage (ICH), the prognostic value of lipid parameters is not fully known. We aimed to determine the association between lipid parameters on admission and clinical outcomes in acute ICH patients. Methods: This study is a post-hoc analysis of the SAMURAI-ICH study, which was a prospective, multicenter, observational study. Hyperacute (hospitalized &lt;3 hours from onset) ICH patients were included. Serum TC, triglyceride (TG), high-density lipoprotein cholesterol (HDLC) and low-density lipoprotein cholesterol (LDLC) were measured on admission. Clinical outcomes were hematoma expansion (&gt;33% increase), neurological deterioration (a decrease of ≥2 in GCS or an increase of ≥4 in NIHSS from baseline to 72 hours), favorable outcome (3-month mRS 0-2) and unfavorable outcome (3-month mRS 4-6). Results: Of the 204 patients (78 women; 66±12 years; median baseline NIHSS, 13 [8-17]), a statin was prescribed in 16 (8%). Of all, 35 (17%) showed hematoma expansion, 16 (8%) experienced neurological deterioration, and 80 (of 199 with premorbid mRS 0-2, 40%) and 84 (41%) had favorable and unfavorable outcomes, respectively. Levels of TC, TG, HDLC and LDLC were 196±40, 125±69, 59±17and 112±34mg/dl, respectively. On multivariate regression analyses adjusted for established prognostic predictors, TG (odds ratio per 10mg/dl [OR], 1.06; 95% confidence interval [CI], 1.002-1.13; p=0.042) was associated with hematoma expansion, and HDLC (OR, 1.30; 95% CI, 1.04-1.65; p=0.024) was positively, and LDLC (OR, 0.89; 95% CI, 0.80-0.999; p=0.048) was inversely associated with favorable outcome. Although prior statin use was not associated with any clinical outcomes, HDLC (OR, 1.20; 95% CI, 0.95-1.53; p=0.123) and LDLC (OR, 0.90; 95% CI, 0.79-1.01; p=0.071) were no more significantly associated with favorable outcome after excluding patients with prior statin. No parameters were significantly associated with neurological deterioration and unfavorable outcome. Conclusions: High TG level was associated with hematoma expansion. High HDLC and low LDLC levels were associated with independence at 3 months after onset in patients with acute ICH.

Intravenous Nicardipine Dosing for Blood Pressure Lowering in Acute Intracerebral Hemorrhage: The Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-Intracerebral Hemorrhage Study

Intravenous nicardipine is commonly used to reduce elevated blood pressure in acute intracerebral hemorrhage (ICH). We determined factors associated with nicardipine dosing and the association of dose with clinical outcomes in hyperacute ICH. Hyperacute (<3 hours from onset) ICH patients with initial systolic blood pressure (SBP) greater than 180 mm Hg were included. All patients initially received 5 mg/hour of intravenous nicardipine. The dose was adjusted to maintain SBP between 120 and 160 mm Hg. Associations of maximum hourly and total doses with early neurologic deterioration (END), hematoma expansion (>33%), and modified Rankin Scale score 4-6 at 3 months were assessed. Two hundred six patients (81 women, 65.8 ± 11.8 years) were studied. Initial SBP was 201.9 ± 15.9 mm Hg. Maximum and total nicardipine doses were 9.1 ± 4.2 mg/hour and 123.7 ± 100.2 mg/day, respectively. Multivariate analyses revealed that men (standardized regression coefficient [β] = .20, P = .0030 for maximum dose; β = .25, P = .0002 for total dose), age (β = -.28, P = .0002; β = -.25, P = .0005), and initial SBP (β = .19, P = .0018; β = .18, P = .0021) were independently associated with both maximum and total doses. Body weight (β = .20, P = .0084) was independently associated with total dose. After multivariate adjustment, maximum dose (per 1 mg/hour; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.09-1.45) was independently, and total dose (per 10 mg/day; OR, 1.06; 95% CI, .998-1.132) tended to be independently, associated with END. Nicardipine dose was not associated with hematoma expansion or 3-month outcome. Nicardipine dose is roughly predictable with sex, age, body weight, and initial SBP in acute ICH. The maximum dose was associated with neurologic deterioration.

Blood pressure variability on antihypertensive therapy in acute intracerebral hemorrhage: the Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-intracerebral hemorrhage study.

The associations between early blood pressure (BP) variability and clinical outcomes in patients with intracerebral hemorrhage after antihypertensive therapy, recently clarified by a post hoc analysis of Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial 2 (INTERACT2), were confirmed using the Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI)-intracerebral hemorrhage study cohort. Patients with hyperacute (<3 hours from onset) intracerebral hemorrhage with initial systolic BP (SBP) >180 mm Hg were registered in a prospective, multicenter, observational study. All patients received antihypertensive therapy based on a predefined standardized protocol to lower and maintain SBP between 120 and 160 mm Hg using intravenous nicardipine. BPs were measured hourly during the initial 24 hours. BP variability was determined as SD and successive variation. The associations between BP variability and hematoma expansion (>33%), neurological deterioration within 72 hours, and unfavorable outcome (modified Rankin Scale, 4-6) at 3 months were assessed. Of the 205 patients, 33 (16%) showed hematoma expansion, 14 (7%) showed neurological deterioration, and 81 (39%) had unfavorable outcomes. The SD and successive variation of SBP were 13.8 (interquartile range, 11.5-16.8) and 14.9 (11.7-17.7) mm Hg, respectively, and those of diastolic BP were 9.4 (7.5-11.2) and 13.1 (11.2-15.9) mm Hg, respectively. On multivariate regression analyses, neurological deterioration was associated with the SD of SBP (odds ratio, 2.75; 95% confidence interval, 1.45-6.12 per quartile) and the successive variation of SBP (2.37; 1.32-4.83), and unfavorable outcome was associated with successive variation of SBP (1.42; 1.04-1.97). Hematoma expansion was not associated with any BP variability. SBP variability during the initial 24 hours of acute intracerebral hemorrhage was independently associated with neurological deterioration and unfavorable outcomes. Stability of antihypertensive therapy may improve clinical outcomes.

Abstract T P233: Intravenous Nicardipine Dosage for Blood Pressure Lowering in Acute Intracerebral Hemorrhage: The SAMURAI-ICH Study

Purpose: Intravenous nicardipine is commonly used to reduce elevated blood pressure (BP) in acute intracerebral hemorrhage (ICH). We determined factors associated with nicardipine dose and the association of the dose with clinical outcomes in hyperacute ICH. Methods: Hyperacute (&lt;3 h from onset) ICH patients with initial systolic BP (SBP) &gt;180 mmHg were registered in a multicenter observational study (the SAMURAI-ICH study). All patients initially received 5mg/h of intravenous nicardipine to lower BP. The dose was adjusted to maintain SBP between 120 and 160 mmHg based on BPs measured every 15 min during the initial 2 h and every 60 min in the following 22 h. Maximum hourly and total doses during the initial 24 h were calculated. Associations of the doses with neurological deterioration (a decrease of ≥2 in GCS or an increase of ≥4 in NIHSS score at 72 h after treatment initiation), hematoma expansion (&gt;33% from baseline to 24 h), and unfavorable outcome (modified Rankin Scale score 4-6 at 3 months) were assessed. Results: Of 211 patients in the registry, 206 patients (81 women, 65.8±11.8 years old) whose nicardipine data were available throughout 24-h observation were studied. Initial BP was 201.9±15.9/107.9±15.1 mmHg. Median time to reach target SBP range was 30 min (IQR 15-45). Maximum and total doses were 9.1±4.2mg/h and 123.7±100.2mg/day, respectively. Multivariate analyses revealed that male sex [standardized regression coefficient (β)=0.20, p=0.0030 for maximum dose; β=0.25, p=0.0002 for total dose], age (β= -0.28, p=0.0002; β= -0.25, p=0.0005) and initial SBP (β=0.19, p=0.0018; β=0.18, p=0.0021) were independently associated with both maximum and total doses. Body weight (β=0.20, p=0.0084) was independently associated with total dose. After multivariate adjustment, maximum dose (per 1mg/h; OR 1.25, 95% CI 1.09-1.45; p=0.0022) was independently and total dose (per 10mg/day; OR 1.06, 95% CI 0.998-1.132; p=0.0555) tended to be associated with neurological deterioration. Nicardipine dose was not associated with hematoma expansion and unfavorable outcome. Conclusions: Nicardipine dosage is roughly predictable with sex, age, body weight and initial SBP in acute ICH. Maximum hourly nicardipine dose was associated with neurological deterioration.

Abstract T P235: Clinical Significance of Continuous Antihypertensive Therapy Throughout the Initial 24 Hours in Hyperacute Intracerebral Hemorrhage: The Samurai-ich Study

BACKGROUND and PURPOSE: Blood pressure (BP) lowering may be beneficial for patients with hyperacute intracerebral hemorrhage (ICH). Although several trials including INTERACT 2 and ATACH II have a design of the strict BP lowering during the initial 24 hours, shorter duration may be enough since active bleeding may not last 24 hours. We aimed to examine the associations between sequential systolic BP levels during antihypertensive treatment (AHT) and clinical outcomes in acute ICH patients. METHODS: Hyperacute (180 mmHg were registered in a prospective, multicenter, observational study, the SAMURAI-ICH study (Koga J Hypertens 2012;30:2357). All patients received intravenous AHT, based on a predefined standardized protocol to lower and maintain SBP between 120 and 160 mmHg using intravenous nicardipine. BPs were measured hourly in the initial 24 hours. The mean of 8 SBP levels during 1 to 8, 9 to 16, and 17 to 24 hours after the initiation of AHT were calculated, and referred to as the 1st, 2nd and 3rd mSBPs, respectively. The associations between mSBPs and neurological deterioration (a decrease of ≥2 in GCS or an increase of ≥4 in NIHSS score), hematoma expansion (&gt;33% in volume), and unfavorable outcome (modified Rankin Scale score 4-6 at 3 months) were assessed. RESULTS: 211 patients (81 women, median age 65 [IQR, 58-74] years, median initial NIHSS score 13 [8-17]) were included. The baseline hematoma volume was 10.2 (5.6-19.2) mL. Neurological deterioration was observed in 17 patients (8%), hematoma expansion in 36 (17%), and unfavorable outcome in 87 (41%). The 1st, 2nd, and 3rd mSBPs were 132 (126-138), 131 (125-140), and 137 (130-144) mmHg, respectively. The 1st (OR 2.41, 95%CI 1.34-4.69 per 10-mmHg) and 2nd mSBPs (2.08; 1.20-3.80) were independently associated with neurological deterioration (17 patients) and the 2nd (1.40; 1.02-2.00) and 3rd mSBPs (1.45; 1.05-2.05) were associated with unfavorable outcome (87 patients), although no mSBPs were associated with hematoma expansion (36 patients). CONCLUSIONS: Continuation of AHT throughout the initial 24 hours may ameliorate clinical outcomes.

Abstract W P251: Clinical and Imaging Characteristics of Hyper-Acute Intracerebral Hemorrhage

Background: Most descriptive studies of intracerebral hemorrhage (ICH) use cases from hospital registries or large stroke databases. The clinical, imaging, and outcome characteristics for patients presenting acutely after symptom onset, and found to have primary ICH on imaging in the emergency department (ED) is not well described. Methods: Cases presenting to the ED via ambulance in the first 2 hours after symptom onset with intracerebral hemorrhage on initial imaging were identified from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 clinical trial of intravenous magnesium vs. placebo. All subjects provided consent in the field and were transported to their usual care hospital, and no guidance was provided on treatment. Results: Of 1700 stroke cases presenting &lt;2 hours from onset, there were 369 (22%) cases with primary ICH. Primary ICH cases had a mean [SD] age of 65 [13] years, 34% women, 79% White race, 34% Hispanic ethnicity, 80% pre-exisitng hypertension, 20% diabetes, 18% smokers; they were assessed in the field by paramedics a median [IQR] of 23 [15-40] and arrived in the ED 58 [46-77] minutes after onset. Median Glasgow Coma Scale was 15 [15-15] in the field and 15 [10-15] in the ED. Initial CT demonstrated ICH on the right in 61%, left in 39% and bilateral in 1. There was concurrent intraventricular hemorrhage in 41%, subarachnoid hemorrhage in 11%, and subdural hemorrhage in &lt;1%. Mean [SD] hematoma volume was 29.2 [38.6] cc. At three months 30% had a good outcome [MRS 0-2] and 44% were dead or bedridden [MRS 5-6]. Younger age, absence of diabetes, smaller volume of hemorrhage, absence of intraventriuclar hemorrhage, and less severe clinical deficit in the field and in the ED was associated with good outcome. Conclusions: We describe the characteristics of hyper-acute primary ICH presenting to the ED, the population most likely to respond to acute treatments aimed at improving outcomes.

Abstract 199: Antihypertensive Utilization in Hyperacute Intracerebral Hemorrhage Presenting to the Emergency Room

Background: There is wide variability in approaches to treating hypertensive primary intracerebral hemorrhage (ICH). We sought to characterize the types of antihypertensive agents and the rapidity with which these agents are utilized in a cohort of severely hypertensive (SH) ICH patients presenting to the emergency department (ED) &lt;2 hours from symptom onset. Methods: Cases presenting to the ED via ambulance in the first 2 hours after symptom onset with intracerebral hemorrhage on initial imaging were identified from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 clinical trial of intravenous magnesium vs. placebo. All subjects provided consent in the field and were transported to their usual care hospital, and no guidance was provided on treatment. We defined SH ICH as having a SBP&gt;180 at presentation. Results: Of 1700 stroke there were 369 (22%) cases with primary ICH and 220 cases (60%) of hypertensive ICH. They were evaluated in 53 separate EDs, with 175 cases (47%) at primary stroke centers (PSC). ICH cases had a mean [SD] age of 65 [13] years, 34% women, 79% White race, 34% Hispanic ethnicity, 80% pre-exisitng hypertension, 20% diabetes, 18% smokers; they were assessed in the field by paramedics a median [IQR] of 23 [15-40] and arrived in the ED 58 [46-77] minutes after onset. Overall 62% of ICH received antihypertensive (80% of ICH-SH, 39% ICH nonSH, p&lt;0.001). Time in minutes from ED arrival to initiation of antihypertensive agent was 109 [SD160] in ICH-SH and 116 [SD198] in ICH-nonSH. Of the 214 who received antihypertensive therapy, 122 received short-acting/bolus therapy only, 70 continuous infusion only and 23 received both. The most commonly used short-acting/bolus therapy in the ED was labetalol in 111, hydralazine in 8, and enalapril in 5. The most commonly used continuous infusion was nicardipine (41), nitroprusside (35) and labetalol infusion (11). SBP was still elevated &gt;180 in 37 (10%) At 4 hours after presentation. Time from ED to treatment was shorter at PSC EDs (73 vs. 144 minutes, p&lt;0.001). Conclusion: There is wide variability in antihypertensive use among emergency departments in the studied geographic area. Despite high rates of treatment, there was a delay of 109 minutes in initiating therapy after ED arrival in ICH-SH.

Continuous Antihypertensive Therapy Throughout the Initial 24 Hours of Intracerebral Hemorrhage

A short duration (<24 hours) of antihypertensive therapy (AHT) after acute intracerebral hemorrhage (ICH) may be sufficient because active bleeding generally ceases within several hours. We aimed to determine the association between sequential systolic blood pressure (SBP) levels during AHT and outcomes in ICH patients. In 211 hyperacute ICH patients who underwent AHT based on predefined protocol, the mean of hourly SBP (mSBP) measurements was calculated over 1 to 8 hours (first mSBP), 9 to 16 hours (second mSBP), and 17 to 24 hours (third mSBP) after the initiation of AHT. Outcomes included neurological deterioration (72-hour Glasgow Coma Scale decrease ≥2 or National Instititutes of Health Stroke Scale increase ≥4), hematoma expansion (>33%), and unfavorable outcome (3-month modified Rankin Scale score 4-6). The median first, second, and third mSBPs were 132, 131, and 137 mm Hg, respectively. A higher first mSBP (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.34-4.69 per 10 mm Hg) or second mSBP (OR, 2.08; 95% CI, 1.20-3.80) was independently associated with neurological deterioration, and a higher second mSBP (OR, 1.40; 95% CI, 1.02-2.00) or third mSBP (OR, 1.45; 95% CI, 1.05-2.05) was associated with unfavorable outcome. None of the mSBPs was associated with hematoma expansion. The continuation of AHT throughout the initial 24 hours after ICH may improve outcomes.

Letter by Aries et al Regarding Article, “Systolic Blood Pressure After Intravenous Antihypertensive Treatment and Clinical Outcomes in Hyperacute Intracerebral Hemorrhage: The Stroke Acute Management With Urgent Risk-Factor Assessment and Improvement-Intracerebral Hemorrhage Study”

We read with interest the article of Sakamoto et al1 about the results of the observational The Stroke Acute Management With Urgent Risk-Factor Assessment and Improvement-Intracerebral Hemorrhage (SAMURAI-ICH) study. Patients with acute ICH and severe hypertension (>200 mm Hg at presentation) received intravenous nicardipine to achieve systolic blood pressure (SBP) levels between 120 and 160 mm Hg for 24 hours. Although the SBP interval groups seem not balanced completely in number of patients (Figure 2),1 patients with the lowest achieved SBP values (<130 mm Hg; n=33) had the lowest proportion of …

Response to Letter Regarding Article, “Systolic Blood Pressure After Intravenous Antihypertensive Treatment and Clinical Outcomes in Hyperacute Intracerebral Hemorrhage: The Stroke Acute Management With Urgent Risk-Factor Assessment and Improvement-Intracerebral Hemorrhage Study”

We thank Dr Aries and his colleagues for their interest in our article and their valuable suggestions on this topic. As we know, in our study, higher mean achieved systolic blood pressure (mean aSBP) was associated with neurological deterioration (multivariable-adjusted odds ratio, 4.43; 95% confidence interval, 1.98–9.90 for every 10-mm Hg increment of mean aSBP), hematoma expansion (odds ratio, 1.80; 95% confidence interval, 1.08–2.98), and unfavorable outcome (odds ratio, 2.00; 95% confidence interval, 1.23–3.26).1 We used the absolute indicator (mean aSBP), …