Because our incompetent stroke medical 'professionals' still haven't figured out an EXACT BLOOD PRESSURE MANAGEMENT PROTOCOL post stroke! And YOU bear the failure of that! Hope your competent? doctor guesses correctly because the poor outcome happens to you! Your doctor gets off scot-free and still gets paid! 

Acute Blood Pressure Lowering and Risk of Ischemic Lesions on MRI After Intracerebral Hemorrhage

Ken S. Butcher, MD, PhD¹; Brian Buck, MD, PhD²; Dar Dowlatshahi, MD^3,4; et al Laura C. Gioia, MD, MSc⁵; Mahesh Kate, MD, MSc²; Ana C. Klahr, PhD⁶; Ashwin Sivasubramaniam, MBBS¹; Ashfaq Shuaib, MBBS²; Alan Wilman, PhD⁷; Vijay K. Sharma, MD⁸; Georgios Tsivgoulis, MD, PhD⁹; Christos Krogias, MD¹⁰; Ashkan Shoamanesh, MD¹¹

Author Affiliations Article Information

JAMA Neurol. Published online April 21, 2025. doi:10.1001/jamaneurol.2025.0586

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• Editorial
  Do the Benefits of Blood Pressure Control in ICH Outweigh the Risks?
  Jessica Magid-Bernstein, MD, PhD; Santosh B. Murthy, MD, MPH
  JAMA Neurology

Key Points

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.

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.

Introduction

Current guidelines indicate that systolic blood pressure (SBP) should be treated to a target range of 130 to 140 mm Hg in acute intracerebral hemorrhage (ICH).¹ This intervention is supported by randomized clinical trials demonstrating intensive blood pressure (BP) reduction may improve clinical outcomes.^2-4 None of these trials systematically assessed for ischemic injury with diffusion-weighted imaging (DWI), which is the optimal investigation given its sensitivity for small-volume infarcts.⁵

Cross-sectional magnetic resonance imaging (MRI) studies in acute and subacute ICH indicate that DWI lesions remote from the hematoma occur in 11% to 59% of patients with ICH.^6-18 Although the etiology of these lesions is unknown, they have been hypothesized to represent ischemia, making them relevant to the management of BP in patients with acute ICH, as a drop in cerebral perfusion pressure may precipitate or aggravate ischemic injury.

Retrospective observational studies have yielded conflicting results with respect to the association between DWI lesions and BP. A pooled analysis of retrospective studies indicated that lower BP was not associated with an increased risk of DWI lesions.¹⁹ However, other studies demonstrated significant correlations between baseline BP and/or treatment with antihypertensive agents and DWI lesion incidence.^6,15 In a secondary analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial, DWI lesions were not associated with intensive SBP reduction with nicardipine, although this was a post hoc analysis in a study subset.¹³ The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial 2 (ICHADAPT-2) was designed to test the hypothesis that SBP reduction in acute ICH increases the incidence of DWI lesions.