Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage
A Secondary Analysis of a Randomized Clinical Trial
Andrea Morotti, MD1,2; H. Bart Brouwers, MD, PhD3; Javier M. Romero, MD2,4; et al Michael J. Jessel, BS2; Anastasia Vashkevich, BA2; Kristin Schwab, BA2; Mohammad Rauf Afzal, MD5; Christy Cassarly, PhD6; Steven M. Greenberg, MD, PhD2; Renee Hebert Martin, PhD6; Adnan I. Qureshi, MD5; Jonathan Rosand, MD, MSc1,2; Joshua N. Goldstein, MD, PhD1,2,7; for the Antihypertensive Treatment of Acute Cerebral Hemorrhage II and Neurological Emergencies Treatment Trials Investigators
Author Affiliations Article Information
JAMA Neurol. Published online June 19, 2017. doi:10.1001/jamaneurol.2017.1014
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.
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