![]() ![]() To explore the role of CSVD in ICH, we performed a preplanned secondary analysis of MRI images obtained during the ATACH-2 trial of intensive BP reduction in ICH. The results of the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial offer a powerful opportunity to examine the association of CMBs, blood pressure (BP) management, hematoma expansion, and outcome in ICH. 3, 6 Finally, CMBs may have additional important clinical implications as predictors of stroke-related outcome and mortality. 4, 5 On the other hand, the thickened vessel walls associated with high CMB counts 6 may be more resistant to secondary vessel rupture from perihematomal mechanical shear stress during hematoma expansion, limiting hematoma growth. 3 - 5 On the one hand, it might be thought that more severe CSVD marks more fragile vessels with higher risk of continued bleeding after ICH. Observational data characterizing the association between CMBs and hematoma expansion have been conflicting. While many analyses have examined whether CSVD subtypes influence risk of developing incident ICH (or recurrent ICH), one intriguing possibility is that their presence can be used clinically during acute ICH to mark those at highest risk of ongoing bleeding and hematoma expansion. 2 In both CSVD subtypes, advanced disease (marked by increasing CMB counts) is characterized histopathologically by thickened vessel walls. 1 Among patients with intracerebral hemorrhage (ICH), CMBs are highly prevalent and have evolved as radiological markers of underlying cerebral small vessel disease (CSVD), representing most notably hypertensive arteriopathy (arteriolosclerosis) (deep CMBs) or cerebral amyloid angiopathy (CAA) (strictly lobar CMBs). ![]() Trial Registration Identifier: NCT01176565Ĭerebral microbleeds (CMBs) are remnants of prior cerebral microhemorrhages at the level of arterioles and capillaries visualized on blood-sensitive magnetic resonance imaging (MRI) sequences. Risk of hematoma expansion was also similar, and no significant interaction between treatment and CMBs was observed (interaction coefficient, 0.62 95% CI, −1.08 to 2.31 P = .48).Ĭonclusions and Relevance Cerebral microbleeds are highly prevalent among patients with ICH but do not seem to influence response to acute intensive BP treatment. Risk of poor outcome was similar for those assigned to intensive vs standard acute BP lowering among patients with CMBs (relative risk, 1.19 95% CI, 0.61-2.33 P = .61) and those without CMBs (relative risk, 1.42 95% CI, 0.43-4.70 P = .57), and no significant interaction was observed (interaction coefficient, 0.18 95% CI, −1.20 to 1.55 P = .80). Forty-six of 157 (29.3%) patients had poor outcome (modified Ranking Scale score, ≥4), and hematoma expansion was observed in 29 of 144 (20.1%) patients. Cerebral microbleeds were present in 120 patients. Results A total of 167 patients were included their mean (SD) age was 61.9 (13.2) years, and 98 (58.7%) were male. The secondary outcome of interest was hematoma volume expansion of at least 33% on a CT scan obtained 24 hours after randomization compared with the entry scan. Main Outcomes and Measures The primary outcome of interest was death or disability (modified Ranking Scale score, 4-6) at 3 months. Eight hundred thirty-three participants were excluded, leaving 167 who had an interpretable axial T2*-weighted gradient-recalled echo sequence on magnetic resonance imaging to assess CMBs for inclusion in these subgroup analyses. Eligible participants were aged at least 18 years with ICH volumes less than 60 mL on computed tomography (CT) and a Glasgow Coma Scale score of at least 5 on initial assessment, in whom study drug could be initiated within 4.5 hours of symptom onset. ![]() Participants were enrolled between May 2011 and September 2015 and followed up for 3 months. Analyses followed the intent-to-treat paradigm. The ATACH-2 was an open-label international randomized clinical trial that investigated optimal acute BP lowering in 1000 patients with acute ICH. Objectives To characterize cerebral microbleeds (CMBs) in acute ICH and to assess the potential for interaction between underlying small vessel disease (as indicated by CMB number and location) and assignment to acute intensive BP targeting for functional outcomes and hematoma expansion.ĭesign, Setting, and Participants Preplanned subgroup analyses in the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial were performed. Importance Response to intensive blood pressure (BP) lowering in acute intracerebral hemorrhage (ICH) might vary with the degree of underlying cerebral small vessel disease. Shared Decision Making and Communication.Scientific Discovery and the Future of Medicine.Health Care Economics, Insurance, Payment.Clinical Implications of Basic Neuroscience.Challenges in Clinical Electrocardiography. ![]()
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