Blood pressure reduction and noncontrast CT markers of intracerebral hemorrhage expansion

Abstract

Objective: To validate various noncontrast CT (NCCT) predictors of hematoma expansion in a large international cohort of ICH patients and investigate whether intensive blood pressure (BP) treatment reduces ICH growth and improves outcome in patients with these markers.

Methods: We analyzed patients enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) randomized controlled trial. Participants were assigned to intensive (systolic BP <140 mm Hg) vs standard (systolic BP <180 mm Hg) treatment within 4.5 hours from onset. The following NCCT markers were identified: intrahematoma hypodensities, black hole sign, swirl sign, blend sign, heterogeneous hematoma density, and irregular shape. ICH expansion was defined as hematoma growth >33% and unfavorable outcome was defined as modified Rankin Scale score >3 at 90 days. Logistic regression was used to identify predictors of ICH expansion and explore the association between NCCT signs and clinical benefit from intensive BP treatment.

Results: A total of 989 patients were included (mean age 62 years, 61.9% male), of whom 186/869 experienced hematoma expansion (21.4%) and 361/952 (37.9%) had unfavorable outcome. NCCT markers independently predicted ICH expansion (all p < 0.01) with overall accuracy ranging from 61% to 78% and good interrater reliability (k > 0.6 for all markers). There was no evidence of an interaction between NCCT markers and benefit from intensive BP reduction (all p for interaction >0.10).

Conclusions: NCCT signs reliably identify ICH patients at high risk of hematoma growth. However, we found no evidence that patients with these markers specifically benefit from intensive BP reduction.

Clinicaltrialsgov identifier: NCT01176565.

Figure 1. Effect of treatment assignment on intracerebral hemorrhage expansion, stratified by noncontrast CT markers status

Adjusted for baseline intracerebral hemorrhage volume and time from onset to baseline noncontrast CT. Hematoma expansion was defined as an increase of 33% or more in the hematoma volume from baseline to 24 hours. CI = confidence interval; OR = odds ratio.

Figure 2. Effect of treatment assignment on primary outcome, stratified by noncontrast CT markers status

Adjusted for age, baseline intracerebral hemorrhage volume, admission Glasgow Coma Scale score, and presence of intraventricular hemorrhage. CI = confidence interval; OR = odds ratio.