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Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage: A Secondary Analysis of a Randomized Clinical Trial.
JAMA Neurol. 2017 08 01; 74(8):950-960.JN

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.

Links

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Authors+Show Affiliations

Morotti A
Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston. J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.
Brouwers HB
Department of Neurosurgery, Brain Center Rudolf Magnus University Medical Center, Utrecht, the Netherlands.
Romero JM
J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston. Neuroradiology Service, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston.
Jessel MJ
J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.
Vashkevich A
J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.
Schwab K
J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.
Afzal MR
Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis.
Cassarly C
Department of Public Health Sciences, Medical University of South Carolina, Charleston.
Greenberg SM
J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.
Martin RH
Department of Public Health Sciences, Medical University of South Carolina, Charleston.
Qureshi AI
Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis.
Rosand J
Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston. J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.
Goldstein JN
Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston. J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston. Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston.
Antihypertensive Treatment of Acute Cerebral Hemorrhage II and Neurological Emergencies Treatment Trials Investigators
No affiliation info available

MeSH

AgedAntihypertensive AgentsBlood PressureCerebral HemorrhageComputed Tomography AngiographyFemaleGlasgow Coma ScaleHumansImage Processing, Computer-AssistedLogistic ModelsMagnetic Resonance AngiographyMaleMiddle AgedOutcome Assessment, Health CareRetrospective Studies

Pub Type(s)

Clinical Trial, Phase II
Journal Article
Multicenter Study
Randomized Controlled Trial

Language

eng

PubMed ID

28628707

Clinical Trial Links

Clinical trial which this article describes
Clinical Evaluation of Shengdi Dahuang Decoction in the Treatment of Acute Hemorrhagic Stroke

Citation

Morotti, Andrea, et al. "Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage: a Secondary Analysis of a Randomized Clinical Trial." JAMA Neurology, vol. 74, no. 8, 2017, pp. 950-960.
Morotti A, Brouwers HB, Romero JM, et al. Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage: A Secondary Analysis of a Randomized Clinical Trial. JAMA Neurol. 2017;74(8):950-960.
Morotti, A., Brouwers, H. B., Romero, J. M., Jessel, M. J., Vashkevich, A., Schwab, K., Afzal, M. R., Cassarly, C., Greenberg, S. M., Martin, R. H., Qureshi, A. I., Rosand, J., & Goldstein, J. N. (2017). Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage: A Secondary Analysis of a Randomized Clinical Trial. JAMA Neurology, 74(8), 950-960. https://doi.org/10.1001/jamaneurol.2017.1014
Morotti A, et al. Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage: a Secondary Analysis of a Randomized Clinical Trial. JAMA Neurol. 2017 08 1;74(8):950-960. PubMed PMID: 28628707.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage: A Secondary Analysis of a Randomized Clinical Trial. AU - Morotti,Andrea, AU - Brouwers,H Bart, AU - Romero,Javier M, AU - Jessel,Michael J, AU - Vashkevich,Anastasia, AU - Schwab,Kristin, AU - Afzal,Mohammad Rauf, AU - Cassarly,Christy, AU - Greenberg,Steven M, AU - Martin,Renee Hebert, AU - Qureshi,Adnan I, AU - Rosand,Jonathan, AU - Goldstein,Joshua N, AU - ,, PY - 2017/6/20/pubmed PY - 2017/8/23/medline PY - 2017/6/20/entrez SP - 950 EP - 960 JF - JAMA neurology JO - JAMA Neurol VL - 74 IS - 8 N2 - 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. SN - 2168-6157 UR - https://www.unboundmedicine.com/medline/citation/28628707/Intensive_Blood_Pressure_Reduction_and_Spot_Sign_in_Intracerebral_Hemorrhage:_A_Secondary_Analysis_of_a_Randomized_Clinical_Trial_ L2 - https://jamanetwork.com/journals/jamaneurology/fullarticle/10.1001/jamaneurol.2017.1014 DB - PRIME DP - Unbound Medicine ER -