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Intracranial and Blood Pressure Variability and In-Hospital Outcomes in Intracranial Device-Monitored Patients with Spontaneous Intracerebral Hemorrhage

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Abstract

Background

Spontaneous intracerebral hemorrhage (sICH) is a major health concern and has high mortality rates up to 52%. Despite a decrease in its incidence, fatality rates remain unchanged; understanding and preventing of factors associated with mortality and treatments for these are needed. Blood pressure variability (BPV) has been shown to be a potential modifiable factor associated with clinical outcomes in patients with traumatic intracerebral hemorrhage and sICH. Few data are available on the effect of intracranial pressure (ICP) variability (ICPV) and outcomes in patients with sICH. The goal of our study was to investigate the association between ICPV and BPV during the first 24 h of intensive care unit (ICU) admission and external ventricular drain (EVD) placement, and mortality in patients with sICH who were monitored with an EVD.

Methods

We conducted a single-center retrospective study of adult patients admitted to an ICU with a diagnosis of sICH who required EVD placement during hospitalization. We excluded patients with ICH secondary to other pathological conditions such as trauma, underlying malignancy, or arteriovenous malformation. Blood pressure and ICP measurements were collected and recorded hourly during the first 24 h of ICU admission and EVD placement, respectively. Measures of variability used were standard deviation (SD) and successive variation (SV). Primary outcome of interest was in-hospital mortality, and secondary outcomes were hematoma expansion and discharge home (a surrogate for good functional outcome at discharge). Descriptive statistics and multivariable logistic regressions were performed.

Results

We identified 179 patients with sICH who required EVD placement. Of these, 52 (29%) patients died, 121 (68%) patients had hematoma expansion, and 12 (7%) patients were discharged home. Patient’s mean age (± SD) was 56 (± 14), and 87 (49%) were women. The mean opening ICP (± SD) was 21 (± 8) and median ICH score (interquartile range) was 2 (2–3). Multivariable logistic regression found an association between ICP-SV and ICP-SD and hematoma expansion (odds ratio 1.6 [1.03–2.30], p = 0.035 and odds ratio 0.77 [0.63–0.93] p = 0.009, respectively).

Conclusions

Our study found an association between ICPV and hematoma expansion in patients with sICH monitored with an EVD. Measures of ICPV relating to rapid changes in ICP (ICP-SV) were associated with a higher odds of hematoma expansion, whereas measures relating to tight control of ICP (ICP-SD) were associated with a lower odds of hematoma expansion. One measure of BPV, sytolic blood pressure maximum-minimum (SBP max-min), was found to be weakly associated with discharge home (a surrogate for good functional outcome at hospital discharge). More research is needed to support these findings.

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Critical Care Medicine, The Mount Sinai Hospital, 1468 Madison Ave, New York, NY, 10029, USA

    Stephanie Cardona

  2. Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA

    Hammad Baqai, Fatima Mikdashi, Ayah Aligabi, Julianna Solomon, Hannah Frederick & Nahom Seyoum

  3. Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA

    Joshua Olexa, Jesse A. Stokum & Ashish Sharma

  4. Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA

    Melissa B. Pergakis

  5. Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA

    Quincy K. Tran

  6. University of Maryland School of Medicine, Baltimore, MD, USA

    Quincy K. Tran

  7. Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA

    Quincy K. Tran

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  1. Stephanie Cardona
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Contributions

SC: Conceptualization, data curation, formal analysis, investigation, project administration, visualization, writing—original draft, writing–review and editing. HB: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. FM: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. AA: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. JS: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. HF: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. NS: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. JO: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. JAS: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. AS: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. MBP: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. QKT: Conceptualization, data curation, formal analysis, investigation, visualization, writing—original draft, writing—review and editing. The authors approve of the final manuscript.

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Correspondence to Stephanie Cardona.

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This study was exempted by the institutional review board number HP-00094744.

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Appendix 1

Appendix 1

See Table 4.

Table 4 Continuous and categorical variables used in multivariable logistic regression
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Cardona, S., Baqai, H., Mikdashi, F. et al. Intracranial and Blood Pressure Variability and In-Hospital Outcomes in Intracranial Device-Monitored Patients with Spontaneous Intracerebral Hemorrhage. Neurocrit Care 39, 357–367 (2023). https://doi.org/10.1007/s12028-023-01677-6

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