Cerebral ischemia and deterioration with lower blood pressure target in intracerebral hemorrhage

Objective To determine the incidence and predictors of acute cerebral ischemia and neurologic deterioration in intracerebral hemorrhage (ICH) patients after an institutional protocol change in systolic blood pressure (SBP) target from <160 to <140 mm Hg. Methods We retrospectively compared persons admitted with primary ICH before and after a protocol change in SBP target from <160 to <140 mm Hg. The primary outcomes were presence of acute cerebral ischemia on MRI completed within 2 weeks of ICH and acute neurologic deterioration. Results Of 286 persons with primary ICH, 119 underwent MRI and met inclusion criteria. Sixty-two had a target SBP < 160 mm Hg (group 1) and 57 had a target SBP < 140 mm Hg (group 2). There were no differences between the 2 groups in baseline clinical and radiographic characteristics, but over the first 24 hours of hospitalization, group 2 had lower mean SBP (134 vs 143 mm Hg, p < 0.001) and lower minimum SBP over 72 hours (106 vs 112 mm Hg, p = 0.02). Acute cerebral ischemia was more frequent in group 2 than in group 1 (32% vs 16%; p = 0.047) as was acute neurologic deterioration (19% vs 5%; p = 0.022). A minimum SBP = 120 mm Hg over 72 hours was associated with cerebral ischemia, while no patient with a minimum SBP = 130 mm Hg had cerebral ischemia. Acute cerebral ischemia was significantly associated with worse discharge NIH Stroke Scale score, while SBP target was not. Conclusions Intensive lowering of SBP < 140 mm Hg in acute ICH, particularly allowing SBP < 120 mm Hg, is associated with increased remote cerebral ischemic lesions and acute neurologic deterioration.