Intracerebral Hemorrhage: Intracerebral Hemorrhage (ICH) - Case - - PowerPoint PPT Presentation

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NEUROCRITICAL CARE PROGRAM

UC SF

Intracerebral Hemorrhage: Acute and Long-Term Blood Pressure Management

• J. Claude Hemphill III, MD, MAS

Kenneth Rainin Chair in Neurocritical Care Professor of Neurology and Neurological Surgery University of California, San Francisco Chief of Neurology, San Francisco General Hospital Past-President, Neurocritical Care Society

Disclosures Research Support: NIH/NINDS; Cerebrotech Medical Stock (options): Ornim

Intracerebral Hemorrhage (ICH) - Case

• 55 yo construction exec

– Poorly controlled hypertension – Slumps over table at board meeting

• Arrives at ED 30 min after onset

– GCS 9 – BP 225/110

• What do you do with the BP?

– Now? – Later?

2015 AHA ICH Guidelines

(used IV nicardipine infusions)

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ATACH 2

• N=1000

– Worldwide – 56.2% of participants were Asian – More than half had GCS=15 – Median hematoma volume ~10 cc

• Intervention – intravenous nicardipine infusion for

24 hours to meet systolic blood pressure target

• Outcome – unable to walk or worse

– 38.7% in SBP < 140 mmHg group – 37.1% in SBP < 180 mmHg group

• Trend towards more adverse events at 3 months in

< 140 mmHg group (esp renal [posthoc])

Qureshi NEJM 2016

• Difference in Blood Pressure
• No difference in outcome

Qureshi NEJM 2016

2015 AHA ICH Guidelines New Definition of Hypertension

• American Heart Association recently dramatically

revised its definition of high blood pressure and guidelines for management.

– Whelton JACC 2017

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What About ICH?

Whelton JACC 2017

• “Update” to 2015 AHA/ASA ICH Guidelines as a result of ATACH2
• So what is the target now?
• At UCSF and ZSFG we have changed to SBP < 160 mmHg

BP in ICH – Practical Considerations

• High blood pressure is

– The most common cause of ICH – Is present in most patients with acute ICH regardless of cause of ICH – Is the most important target for primary and secondary prevention of ICH

• Acute BP treatment

– May not be as beneficial as we hoped – Has not been compared against “no treatment” – May be more complex than we hoped » Variability may be bad (Manning Lancet Neurol 2014) » One size may not fit all – Precision Medicine needed

• Example in periop care: Futier JAMA 2017

BP in ICH – Practical Considerations

What to Do?

• Acute BP Management in ICH

– Lower the BP – Select an intermediate target. » SBP < 160 mmHg for at least 3 days?

• Long-term BP Management in ICH

– Select a target. < 130/80 mmHg in most cases – Discharge patient on BP meds and write the target in the chart – Recognize high BP in the office and start treatment (time to dispense with notion of “white coat” hypertension)