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Original Investigation
August 2017

Intensive Blood Pressure Reduction and Spot Sign in Intracerebral HemorrhageA Secondary Analysis of a Randomized Clinical Trial

Author Affiliations
  • 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
  • 2J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
  • 3Department of Neurosurgery, Brain Center Rudolf Magnus University Medical Center, Utrecht, the Netherlands
  • 4Neuroradiology Service, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
  • 5Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis
  • 6Department of Public Health Sciences, Medical University of South Carolina, Charleston
  • 7Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
JAMA Neurol. 2017;74(8):950-960. doi:10.1001/jamaneurol.2017.1014
Key Points

Question  Does the computed tomographic angiography spot sign identify the patients with intracerebral hemorrhage who are most likely to benefit from intensive blood pressure reduction?

Findings  In this secondary analysis of 133 patients with intracerebral hemorrhage nested in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II randomized clinical trial, intensive blood pressure treatment did not improve outcomes in patients with a spot sign. The proportion of patients with a spot sign and a 90-day modified Rankin Scale score of 4 or greater was 20 of 27 in the intensive treatment group vs 10 of 20 in the standard treatment group.

Meaning  Our results showed no clinical benefit of intensive blood pressure reduction in patients with intracerebral hemorrhage and a spot sign.

Abstract

Importance  The computed tomographic angiography (CTA) spot sign is associated with intracerebral hemorrhage (ICH) expansion and may mark those patients most likely to benefit from intensive blood pressure (BP) reduction.

Objective  To investigate whether the spot sign is associated with ICH expansion across a wide range of centers and whether intensive BP reduction decreases hematoma expansion and improves outcome in patients with ICH and a spot sign.

Design, Setting, and Participants  SCORE-IT (Spot Sign Score in Restricting ICH Growth) is a preplanned prospective observational study nested in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) randomized clinical trial. Participants included consecutive patients with primary ICH who underwent a CTA within 8 hours from onset at 59 sites from May 15, 2011, through December 19, 2015. Data were analyzed for the present study from July 1 to August 31, 2016.

Main Outcomes and Measures  Patients in ATACH-II were randomized to intensive (systolic BP target, <140 mm Hg) vs standard (systolic BP target, <180 mm Hg) BP reduction within 4.5 hours from onset. Expansion of ICH was defined as hematoma growth of greater than 33%, and an unfavorable outcome was defined as a 90-day modified Rankin Scale score of 4 or greater (range, 0-6). The association among BP reduction, ICH expansion, and outcome was investigated with multivariable logistic regression.

Results  A total of 133 patients (83 men [62.4%] and 50 women [37.6%]; mean [SD] age, 61.9 [13.1] years) were included. Of these, 53 (39.8%) had a spot sign, and 24 of 123 without missing data (19.5%) experienced ICH expansion. The spot sign was associated with expansion with sensitivity of 0.54 (95% CI, 0.34-0.74) and specificity of 0.63 (95% CI, 0.53-0.72). After adjustment for potential confounders, intensive BP treatment was not associated with a significant reduction of ICH expansion (relative risk, 0.83; 95% CI, 0.27-2.51; P = .74) or improved outcome (relative risk of 90-day modified Rankin Scale score ≥4, 1.24; 95% CI, 0.53-2.91; P = .62) in spot sign–positive patients.

Conclusions and Relevance  The predictive performance of the spot sign for ICH expansion was lower than in prior reports from single-center studies. No evidence suggested that patients with ICH and a spot sign specifically benefit from intensive BP reduction.

Trial Registration  clinicaltrials.gov Identifier: NCT01176565

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