Edinburgh Imaging

05 Nov 21. Featured Paper

Early lowering of blood pressure after acute intracerebral haemorrhage: a systematic review & meta-analysis of individual patient data

Link to paper on The Journal of Neurology, Neurosurgery, & Psychiatry



Tom J Moullaali, Xia Wang, Else Charlotte Sandset, Lisa J Woodhouse, Zhe Kang Law, Hisatomi Arima, Kenneth S Butcher, John Chalmers, Candice Delcourt, Leon Edwards, Salil Gupta, Wen Jiang, Sebastian Koch, John Potter, Adnan I Qureshi, Thompson G Robinson, Rustam Al-Shahi Salman, Jeffrey L Saver, Nikola Sprigg, Joanna M Wardlaw, Craig S Anderson, Philip M Bath On behalf of the Blood Pressure in Acute Stroke (BASC) Investigators



Objective: To summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH).

Methods: A prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE & MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults <7 days after ICH onset.

The primary outcome was function (distribution of scores on the modified Rankin scale) 90 days after randomisation.

Radiological outcomes were absolute (>6 mL) & proportional (>33%) haematoma growth at 24 hours.

Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables & trial as a random effect.

Results: Of 7094 studies identified, 50 trials involving 11 494 patients were eligible & 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6–5.3).

Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (pinteraction=0.031) & agent (pinteraction<0.0001).

Active/intensive BP-lowering interventions clearly reduced absolute (>6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) & relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth.

Interpretation: Overall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding.

The treatment effect appeared to vary according to strategy & agent.


  • Blood pressure (BP)
  • Intracerebral haemorrhage (ICH)



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