Steiner, Thorsten

Background: Systolic blood pressure (SBP) fluctuation is linked to increased death or disability in intracerebral hemorrhage (ICH) patients. We analyzed data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)-2 trial to explore whether the association between SBP fluctuation and 90-day outcomes varies with time from randomization. Methods: We calculated hourly SBP fluctuation based on the difference between maximum and minimum SBP during the first 24 hours post-randomization. Logistic regression models assessed the impact of SBP fluctuation on: 1) death or disability (modified Rankin scale [mRS] 4-6 at 90 days); 2) hematoma expansion (>33% increase in volume on 24-hour CT scan); 3) neurological deterioration within 24 hours (defined as ≥2-point decrease on Glasgow Coma Scale or ≥4-point increase on NIH Stroke Scale); and 4) acute kidney injury (AKI) within 72 hours. Adjustments were made for baseline Glasgow Coma Scale score, intraventricular hemorrhage, hematoma volume, and maximum SBP. Results: The hourly SBP fluctuations according to 90-day outcomes (dichotomized into good outcome, mRS 0-3, and poor outcome, mRS 4-6) in 961 patients with ICH are presented in Figure. The SBP fluctuation at 5 hours (p=0.014) and 6 hours (p=0.014) post randomization were significantly associated with death or disability at 90 days, with positive, but not statistically significant associations observed at all other points up to 13 hours after randomization. Risk of neurological deterioration within 24 hours was highly associated with SBP fluctuation, with the largest association observed between 1 (p<0.001) and 5 (p<0.001) hours following randomization, with significant associations observed up to 22 hours following randomization. Risk of hematoma expansion was associated with SBP fluctuation between 3 (p=0.015) and 8 (p=0.002) hours post randomization. Statistically significant associations between SPB fluctuations and risk of AKI were not observed. Conclusions: The first 8 hours following randomization are critical for reducing SBP fluctuations, as this period most strongly influences both short- and long-term outcomes in ICH patients. These findings suggest this time window is crucial for future interventions aimed at controlling SBP in ICH patients.

Background: There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. Aims: To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced). Summary of review: Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited. Conclusion: The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.