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consistent with the results of previous positron- target systolic blood pressure of 140 mm Hg or
emission tomographic neuroimaging studies, less appears to be a reasonable option for pa-
which failed to show an ischemic penumbra tients with spontaneous intracerebral hemorrhage.
surrounding an intracerebral hematoma.8 Disclosure forms provided by the author are available with the
full text of this article at NEJM.org.
Some limitations of this trial bear mention-
ing. First, more than two thirds of the partici-
From the Cerebrovascular Center, Cleveland Clinic Foundation,
pants were from China. Although the incidence
Cleveland.
of intracerebral hemorrhage in Asian popula-
This article was published on May 29, 2013, at NEJM.org.
tions is more than twice the incidence in other
races, it is not clear that race or ethnicity has a
1. van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A,
major effect on outcome.1 Because more pa-
Klijn CJ. Incidence, case fatality, and functional outcome of in-
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ethnic origin: a systematic review and meta-analysis. Lancet
ly used blood-pressure lowering drug was an
Neurol 2010;9:167-76.
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Though a drug effect seems unlikely, it remains
3. Mendelow AD, Gregson BA, Fernandes HM, et al. Early sur-
a possibility that could limit the generalizability
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of the results. Second, 72% of the patients in taneous supratentorial intracerebral haematomas in the Inter-
national Surgical Trial in Intracerebral Haemorrhage (STICH):
this study had hypertension, and 84% had pri-
a randomised trial. Lancet 2005;365:387-97.
marily deep hemorrhages that were of small vol-
4. Morgenstern LB, Hemphill JC III, Anderson C, et al. Guide-
ume (median, 11 ml). This could also limit the lines for the management of spontaneous intracerebral hemor-
rhage: a guideline for healthcare professionals from the Amer-
generalizability of the results. However, no sig-
ican Heart Association/American Stroke Association. Stroke
nificant differences in the primary outcome were
2010;41:2108-29.
seen on the basis of the region of enrollment or 5. Anderson CS, Huang Y, Arima H, et al. Effects of early inten-
sive blood pressure-lowering treatment on the growth of hema-
the volume or location of the hematoma. Third,
toma and perihematomal edema in acute intracerebral hemor-
no data on intracranial pressure or cerebral per-
rhage: the Intensive Blood Pressure Reduction in Acute Cerebral
fusion pressure were shown for either blood- Haemorrhage Trial (INTERACT). Stroke 2010;41:307-12.
6. Anderson CS, Huang Y, Wang JG, et al. Intensive Blood
pressure group. Though 62% of the patients in
Pressure Reduction in Acute Cerebral Haemorrhage Trial
each group received mannitol, suggesting that
(INTERACT): a randomised pilot trial. Lancet Neurol 2008;7:391-9.
they had increased intracranial pressure or radio- 7. Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure
lowering in patients with acute intracerebral hemorrhage. N Engl
logic evidence of edema, values for intracranial
J Med 2013. DOI: 10.1056/NEJMoa1214609.
pressure were not reported. Patients with elevated
8. Zazulia AR, Diringer MN, Videen TO, et al. Hypoperfusion
intracranial pressure may require a higher mean without ischemia surrounding acute intracerebral hemorrhage.
J Cereb Blood Flow Metab 2001;21:804-10.
arterial pressure to maintain target cerebral
9. Qureshi AI, Palesch YY. Antihypertensive Treatment of Acute
perfusion pressure. In such a population, multi-
Cerebral Hemorrhage (ATACH) II: design, methods, and ration-
modality monitoring may guide individualized ale. Neurocrit Care 2011;15:559-76.
blood-pressure goals.
DOI: 10.1056/NEJMe1305047
The Antihypertensive Treatment of Acute Cere- Copyright © 2013 Massachusetts Medical Society.
n engl j med nejm.org
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