Individualized blood pressure targets in the postoperative care of patients with intracerebral hemorrhage

View More View Less
  • 1 Neurological Intensive Care Unit, Department of Neurology, and
  • 4 Departments of Neuroradiology and
  • 5 Neurosurgery, Medical University of Innsbruck;
  • 2 Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Tyrol, Austria; and
  • 3 School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

Recent guidelines recommend targeting a systolic blood pressure (SBP) < 140 mm Hg in the early management of patients with spontaneous intracerebral hemorrhage (ICH). The optimal SBP targets for ICH patients after hematoma evacuation (HE) remain unclear. Here, the authors aimed to define the optimal SBP range based on multimodal neuromonitoring data.

METHODS

Forty poor-grade ICH patients who had undergone HE and then monitoring of intracerebral pressure, brain tissue oxygen tension (PbtO2), and cerebral metabolism (via cerebral microdialysis [CMD]) were prospectively included. Episodes of brain tissue hypoxia (BTH) (1-hour averaged PbtO2 < 20 mm Hg) and metabolic distress (CMD–lactate/pyruvate ratio [LPR] ≥ 40) were identified and linked to corresponding parameters of hemodynamic monitoring (SBP and cerebral perfusion pressure [CPP]). Multivariable regression analysis was performed using generalized estimating equations to identify associations between SBP levels, PbtO2, and brain metabolism.

RESULTS

The mean patient age was 60 (range 51–66) years and the median [IQR] initial ICH volume was 47 [29–60] ml. In multivariable models adjusted for Glasgow Coma Scale score, probe location, ICH volume, and age, lower SBP was independently associated with a higher risk of BTH (≤ 120 mm Hg: adjusted OR 2.9, p = 0.007; 120–130 mm Hg: adj OR 2.4, p = 0.002; 130–140 mm Hg: adj OR 1.6, p = 0.017) compared to a reference range of 140–150 mm Hg at the level of the foramen interventriculare Monroi, which corresponded to a CPP of 70–80 mm Hg and SBP levels between 150 and 160 mm Hg at the heart level. After exclusion of episodes with mitochondrial dysfunction, SBP targets < 140 mm Hg were associated with higher odds of cerebral metabolic distress (≤ 130 mm Hg: OR 2.5, p = 0.041; 130–140 mm Hg: OR 2.3, p = 0.033). Patients with a modified Rankin Scale score ≥ 5 at neurological ICU discharge more often exhibited BTH than patients with better outcomes (51% vs 10%, p = 0.003).

CONCLUSIONS

These data suggest that lower SPB and CPP levels are associated with a higher risk for BTH. Further studies are needed to evaluate whether a higher SPB target may prevent BTH and improve outcomes.

ABBREVIATIONS adj OR = adjusted odds ratio; APACHE-II = Acute Physiology and Chronic Health Evaluation II; BP = blood pressure; BTH = brain tissue hypoxia; CMD = cerebral microdialysis; CPP = cerebral perfusion pressure; GCS = Glasgow Coma Scale; GEE = generalized estimating equation; HE = hematoma evacuation; ICH = intracerebral hemorrhage; ICP = intracerebral pressure; INTERACT-2 = Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage; LPR = CMD–lactate/pyruvate ratio; mRS = modified Rankin Scale; NICU = neurological ICU; PbtO2 = brain tissue oxygen tension; PiCCO = pulse index continuous cardiac output device; SBP = systolic BP.

Supplementary Materials

    • Supplemental Figures and Table (PDF 1,451 KB)

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Raimund Helbok: Medical University of Innsbruck, Austria. raimund.helbok@tirol-kliniken.at; raimund.helbok@i-med.ac.at.

INCLUDE WHEN CITING Published online April 9, 2021; DOI: 10.3171/2020.9.JNS201024.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Qureshi AI, Ezzeddine MA, Nasar A, . Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007;25(1):3238.

    • Search Google Scholar
    • Export Citation
  • 2

    Rodriguez-Luna D, Piñeiro S, Rubiera M, . Impact of blood pressure changes and course on hematoma growth in acute intracerebral hemorrhage. Eur J Neurol. 2013;20(9):12771283.

    • Search Google Scholar
    • Export Citation
  • 3

    Hemphill JC III, Greenberg SM, Anderson CS, . Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):20322060.

    • Search Google Scholar
    • Export Citation
  • 4

    Steiner T, Al-Shahi Salman R, Beer R, . European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke. 2014;9(7):840855.

    • Search Google Scholar
    • Export Citation
  • 5

    Anderson CS, Heeley E, Huang Y, . Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):23552365.

    • Search Google Scholar
    • Export Citation
  • 6

    Qureshi AI, Palesch YY, Martin R, . Effect of systolic blood pressure reduction on hematoma expansion, perihematomal edema, and 3-month outcome among patients with intracerebral hemorrhage: results from the antihypertensive treatment of acute cerebral hemorrhage study. Arch Neurol. 2010;67(5):570576.

    • Search Google Scholar
    • Export Citation
  • 7

    Qureshi AI, Palesch YY, Barsan WG, . intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375(11):10331043.

    • Search Google Scholar
    • Export Citation
  • 8

    Anderson CS, Huang Y, Wang JG, . Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. 2008;7(5):391399.

    • Search Google Scholar
    • Export Citation
  • 9

    Shrestha GS, Suarez JI, Hemphill JC III. Precision medicine in neurocritical care. JAMA Neurol. 2018;75(12):14631464.

  • 10

    Alizadeh AM, Hassanian-Moghaddam H, Shadnia S, . Simplified acute physiology score II/acute physiology and chronic health evaluation II and prediction of the mortality and later development of complications in poisoned patients admitted to intensive care unit. Basic Clin Pharmacol Toxicol. 2014;115(3):297300.

    • Search Google Scholar
    • Export Citation
  • 11

    Hemphill JC III, Bonovich DC, Besmertis L, . The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891897.

    • Search Google Scholar
    • Export Citation
  • 12

    Garner JS, Jarvis WR, Emori TG, . CDC definitions for nosocomial infections, 1988. Am J Infect Control. 1988;16(3):128140.

  • 13

    American Thoracic Society. Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388416.

    • Search Google Scholar
    • Export Citation
  • 14

    Hanley DF, Thompson RE, Rosenblum M, . Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet. 2019;393(10175):10211032.

    • Search Google Scholar
    • Export Citation
  • 15

    Hutchinson PJ, Jalloh I, Helmy A, . Consensus statement from the 2014 International Microdialysis Forum. Intensive Care Med. 2015;41(9):15171528.

    • Search Google Scholar
    • Export Citation
  • 16

    Le Roux P, Menon DK, Citerio G, . The International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: a list of recommendations and additional conclusions: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Neurocrit Care. 2014;21(suppl 2):S282S296.

    • Search Google Scholar
    • Export Citation
  • 17

    Kothari RU, Brott T, Broderick JP, . The ABCs of measuring intracerebral hemorrhage volumes. Stroke. 1996;27(8):13041305.

  • 18

    Rass V, Solari D, Ianosi B, . Protocolized brain oxygen optimization in subarachnoid hemorrhage. Neurocrit Care. 2019;31(2):263272.

  • 19

    Ponce LL, Pillai S, Cruz J, . Position of probe determines prognostic information of brain tissue PO2 in severe traumatic brain injury. Neurosurgery. 2012;70(6):14921503.

    • Search Google Scholar
    • Export Citation
  • 20

    Hemphill JC III, Morabito D, Farrant M, Manley GT. Brain tissue oxygen monitoring in intracerebral hemorrhage. Neurocrit Care. 2005;3(3):260270.

    • Search Google Scholar
    • Export Citation
  • 21

    Butcher KS, Jeerakathil T, Hill M, . The intracerebral hemorrhage acutely decreasing arterial pressure trial. Stroke. 2013;44(3):620626.

    • Search Google Scholar
    • Export Citation
  • 22

    Ko SB, Choi HA, Parikh G, . Multimodality monitoring for cerebral perfusion pressure optimization in comatose patients with intracerebral hemorrhage. Stroke. 2011;42(11):30873092.

    • Search Google Scholar
    • Export Citation
  • 23

    Schmidt JM, Ko SB, Helbok R, . Cerebral perfusion pressure thresholds for brain tissue hypoxia and metabolic crisis after poor-grade subarachnoid hemorrhage. Stroke. 2011;42(5):13511356.

    • Search Google Scholar
    • Export Citation
  • 24

    Rosenthal G, Hemphill JC III, Sorani M, . Brain tissue oxygen tension is more indicative of oxygen diffusion than oxygen delivery and metabolism in patients with traumatic brain injury. Crit Care Med. 2008;36(6):19171924.

    • Search Google Scholar
    • Export Citation
  • 25

    Gaasch M, Schiefecker AJ, Kofler M, . Cerebral autoregulation in the prediction of delayed cerebral ischemia and clinical outcome in poor-grade aneurysmal subarachnoid hemorrhage patients. Crit Care Med. 2018;46(5):774780.

    • Search Google Scholar
    • Export Citation
  • 26

    Czosnyka M, Smielewski P, Piechnik S, . Cerebral autoregulation following head injury. J Neurosurg. 2001;95(5):756763.

  • 27

    Balbi M, Koide M, Wellman GC, Plesnila N. Inversion of neurovascular coupling after subarachnoid hemorrhage in vivo. J Cereb Blood Flow Metab. 2017;37(11):36253634.

    • Search Google Scholar
    • Export Citation
  • 28

    Coles JP, Fryer TD, Coleman MR, . Hyperventilation following head injury: effect on ischemic burden and cerebral oxidative metabolism. Crit Care Med. 2007;35(2):568578.

    • Search Google Scholar
    • Export Citation
  • 29

    Kurtz P, Schmidt JM, Claassen J, . Anemia is associated with metabolic distress and brain tissue hypoxia after subarachnoid hemorrhage. Neurocrit Care. 2010;13(1):1016.

    • Search Google Scholar
    • Export Citation
  • 30

    Wang E, Ho CL, Lee KK, . Effects of temperature changes on cerebral biochemistry in spontaneous intracerebral hematoma. Acta Neurochir Suppl. 2008;102(335):338.

    • Search Google Scholar
    • Export Citation
  • 31

    Schiefecker AJ, Beer R, Pfausler B, . Clusters of cortical spreading depolarizations in a patient with intracerebral hemorrhage: a multimodal neuromonitoring study. Neurocrit Care. 2015;22(2):293298.

    • Search Google Scholar
    • Export Citation
  • 32

    Jacobsen A, Nielsen TH, Nilsson O, . Bedside diagnosis of mitochondrial dysfunction in aneurysmal subarachnoid hemorrhage. Acta Neurol Scand. 2014;130(3):156163.

    • Search Google Scholar
    • Export Citation
  • 33

    Narotam PK, Morrison JF, Nathoo N. Brain tissue oxygen monitoring in traumatic brain injury and major trauma: outcome analysis of a brain tissue oxygen-directed therapy. J Neurosurg. 2009;111(4):672682.

    • Search Google Scholar
    • Export Citation
  • 34

    Okonkwo DO, Shutter LA, Moore C, . Brain oxygen optimization in severe traumatic brain injury phase-II: a phase II randomized trial. Crit Care Med. 2017;45(11):19071914.

    • Search Google Scholar
    • Export Citation
  • 35

    Kett-White R, Hutchinson PJ, Al-Rawi PG, . Adverse cerebral events detected after subarachnoid hemorrhage using brain oxygen and microdialysis probes. Neurosurgery. 2002;50(6):12131222.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 682 682 317
Full Text Views 118 118 36
PDF Downloads 76 76 32
EPUB Downloads 0 0 0