title: Intensive blood pressure lowering in patients with acute intracerebral haemorrhage: clinical outcomes and haemorrhage expansion. Systematic review and meta-analysis of randomised trials.
abstract: BACKGROUND
  It is unclear whether intensive lowering of blood pressure (BP) at the acute phase of intracerebral haemorrhage (ICH) is beneficial. We performed a meta-analysis of randomised controlled trials (RCTs) to assess whether intensive BP lowering in patients with acute ICH is safe and effective in improving clinical outcomes.
  
  
  METHODS
  We searched PubMed, EMBASE and the Cochrane databases for relevant RCTs and calculated pooled OR for 3-month mortality (safety outcome) and 3-month death or dependency (modified Rankin Scale (mRs) ≥3;efficacy outcome), in patients with acute ICH randomised to either intensive BP-lowering or standard BP-lowering treatment protocols. We also investigated the association between treatment arm and ICH expansion at 24 hours. Random effects models with DerSimonian-Laird weights were used.
  
  
  RESULTS
  Five eligible studies including 4360 patients with acute ICH were pooled in meta-analysis. The risk of 3-month mortality was similar between patients randomised to intensive BP-lowering treatment and standard BP-lowering treatment (OR: 0.99; 95% CI: 0.82 to 1.20, p=0.909). Intensive BP-lowering treatment showed a (non-significant) trend for an association with lower 3-month death or dependency risk compared with standard treatment (OR: 0.91; 95% CI: 0.80 to 1.02), p=0.106). Intensive BP reduction was associated with a trend for lower risk of significant ICH expansion compared with standard treatment (OR: 0.82; 95% CI: 0.68 to 1.00, p=0.056), especially in larger RCTs.
  
  
  CONCLUSIONS
  For patients with acute ICH similar to those included in RCTs and without contraindication to acute BP treatment, intensive acute BP lowering is safe, but does not seem to provide an incremental clinical benefit in terms of functional outcomes. The effect of intensive BP lowering on significant haematoma expansion at 24 hours warrants further investigation.
authors.affiliation: Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, Massachusetts, USA.|Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.|Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris-Descartes, INSERM UMR 894, Paris, France.
authors.forename: Gregoire
authors.initials: G
authors.lastname: Boulouis
authors.affiliation: Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, Massachusetts, USA.|Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Morotti
authors.affiliation: Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, Massachusetts, USA.|Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.|Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Joshua N
authors.initials: JN
authors.lastname: Goldstein
authors.affiliation: Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, Massachusetts, USA andreas.charidimou.09@ucl.ac.uk.|Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Andreas
authors.initials: A
authors.lastname: Charidimou
mesh_terms: D000208:Acute Disease; D000959:Antihypertensive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D002543:Cerebral Hemorrhage / Q000188:drug therapy*; D004185:Disability Evaluation; D018450:Disease Progression; D019983:Guideline Adherence; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D017063:Outcome Assessment, Health Care; D016032:Randomized Controlled Trials as Topic
chemical_list: D000959:Antihypertensive Agents
keywords: Acute Therapy; Blood Pressure; Hematoma Expansion; Hypertension; Intracerebral Hemorrhage; Meta-Analysis; Outcome; Stroke