Acute Blood Pressure Lowering andRisk of Ischemic Lesions on MRIAfter Intracerebral Hemorrhage

Ken S. Butcher, MD, PhD1; Brian Buck, MD, PhD2; Dar Dowlatshahi, MD3,4; et al

2025년 04월21일

JAMA Neurol. Published online April 21, 2025 (Original investigation)

DOI: 10.1001/jamaneurol.2025.0586

Abstract

Abstract

Importance  Diffusion-weighted imaging (DWI) lesions have been demonstrated in patients with subacute intracerebral hemorrhage (ICH), suggesting ischemic injury, which may be related to blood pressure (BP) reduction.

Objective  To test the hypothesis that acute intensive BP lowering is associated with DWI lesions after ICH.

Design, Setting, and Participants  The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial 2 (ICHADAPT-2) was a multicenter, randomized, open-label, blinded–end point trial. Between November 2012 and August 2022, patients with ICH presenting within 6 hours of onset were randomized to a systolic BP (SBP) target of less than 140 mm Hg or less than 180 mm Hg. The trial was conducted at 3 comprehensive stroke centers in Canada and Australia, including 1 telestroke referral hub and 1 community stroke hospital. A total of 162 patients with acute ICH were randomized. The primary analysis population was restricted to those undergoing DWI at 48 hours.

Intervention  Patients were randomly assigned to an acute SBP target of less than 140 mm Hg or less than 180 mm Hg.

Main Outcome and Measure  The primary end point was the incidence of acute DWI lesions on brain magnetic resonance imaging obtained 48 ± 12 hours after randomization.

Results  DWI was obtained in 79 (48% female) patients with a mean (SD) age of 71 (13) years and median baseline ICH volume of 11.2 (range, 0.5-122.2) mL. The median times from onset to randomization and DWI were 3.17 (range, 0.7-14.6) hours and 51.6 (range, 17.0-121.4) hours, respectively. Mean (SD) baseline SBP was 183 (22) mm Hg in the less than 140 mm Hg target group and 181 (28) mm Hg in the less than 180 mm Hg target group. Mean SBP was lower over the 48-hour period after randomization in the less than 140 mm Hg group (mean difference, 18.9 mm Hg [95% CI, 17.6-20.2]; P < .001). DWI lesions were detected in 13 of 42 patients (31%) in the less than 140 mm Hg group and 14 of 37 patients (38%) in the less than 180 mm Hg group (odds ratio, 0.74 [95% CI, 0.12-4.64]; P = .32). The median number of DWI lesions (1 [95% CI, 1-10] vs 1.5 [95% CI, 1-10]; P = .26) and total DWI lesion volume (0.1 [95% CI, 0.01-41.3] mL vs 0.3 [95% CI, 0.02-2.03] mL; P = .17) were not different in the less than 140 mm Hg and less than 180 mm Hg groups.

Conclusions and Relevance  DWI lesion frequency and volume were unaffected by intensive antihypertensive therapy. These results support the safety of early BP reduction in acute ICH.

Key Point

Question  Does acute blood pressure (BP) reduction increase the incidence of subacute ischemic lesions in spontaneous intracerebral hemorrhage (ICH)?

Findings  The frequency of ischemic lesions detected with diffusion-weighted magnetic resonance imaging at 48 hours did not increase in patients with ICH randomized to an intensive systolic BP target of less than 140 mm Hg within 6 hours of onset, compared with those with a target of less than 180 mm Hg.

Meaning  Study findings support the safety of systolic BP reduction to a target of less than 140 mm Hg in patients with acute ICH.

요약

• 중요성 : 확산강조영상(DWI) 병변은 아급성 뇌내출혈(ICH) 환자에서 관찰되며, 이는 허혈성 손상을시사한다. 이러한 병변은 혈압 감소와 연관이 있을 수 있다.

• 목적 : 급성기 집중적인 혈압 강하가 ICH 환자에서 DWI 병변과 연관되어 있는지를 검증하기

위함이다.

• 연구 설계 및 대상 :

-ICHADAPT-2 임상시험은 다기관, 무작위배정, 공개 라벨, 블라인드 종료지점 평가연구이다.

-2012년11월~2022년8월까지 발병 6시간 이내 ICH 환자를 대상으로 하였다.

-SBP목표를140 mmHg미만 또는 180 mmHg 미만으로 무작위 배정하였다.

-연구는 캐나다와 호주의 3개 뇌졸중 센터(텔레스트로크 포함)에서 수행되었다.

-총162명의 환자가 등록, 48시간 내 DWI MRI를 시행한 환자가 주요 분석 대상이다.

• 중재 : SBP &lt;140mmHg 또는 SBP &lt; 180mmHg 두 그룹으로 무작위 배정되었다.

• 주요 결과지표 : 48±12시간 내 MRI에서 DWI 병변의 발생률

• 결과 :

-DWI 시행한 환자 수: 79명 (여성 48%)

-평균연령: 71 세(± 13세)

-중앙값 ICH 부피: 11.2 mL (범위: 0.5–122.2 mL)

-발병부터 무작위 배정까지 시간: 중앙값 3.17시간

-무작위 배정부터 DWI까지 시간: 중앙값 51.6시간

-SBP 목표 그룹별 평균 초기 혈압:

<140 mmHg 그룹: 183 mmHg

<180 mmHg 그룹: 181 mmHg

-48시간 동안 SBP 평균 차이: 18.9 mmHg 낮음 (95% CI: 17.6–20.2, P &lt; .001)

-DWI 병변 발견율: 차이 없음 (OR 0.74, 95% CI 0.12–4.64, P = .32)

<140 mmHg 그룹: 13/42명 (31%)

<180 mmHg 그룹: 14/37명 (38%)

-DWI 병변 수 및 부피도 두 그룹 간에 통계적으로 유의한 차이 없음

병변 수 중앙값: 1 vs 1.5 (P = .26)

병변 총 부피: 0.1 mL vs 0.3 mL (P = .17)

• 결론 : 집중적인 항고혈압 치료는 DWI 병변의 빈도나 부피에 영향을 미치지 않았다. 이 결과는 급성 ICH에서 조기 혈압 강하가 안전하다는 것을 지지한다.

Figure 2.  Mean Systolic Blood Pressure (SBP) Over First 48 Hours After Randomization in Both Treatment Groups

Table 3.  Primary and Secondary Outcomes Between Treatment Groups