With Brain Microbleeds, Can Patients Tolerate Lower Blood Pressure?

MedicalResearch.com Interview with:

Dr. Joshua Goldstein

Dr. Joshua Goldstein

Dr. Joshua Goldstein MD, PhD
J. Philip Kistler Stroke Research Center
Division of Neurocritical Care and Emergency Neurology, Department of Neurology MGH
Harvard Medical School, Boston Department of Emergency Medicine
Massachusetts General Hospital
for the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) and the Neurological Emergencies Treatment Trials (NETT) Network Investigators  

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: It’s hard to know how aggressively to lower blood pressure in acute intracerebral hemorrhage (ICH).  Randomized controlled trials have been conflicting. We thought that we could use the presence of severe small vessel disease (SVD) – manifested by microbleeds seen on brain magnetic resonance imaging (MRI) – to guide treatment decisions.  On the one hand, those with severe SVD may be most vulnerable to continued bleeding, and specifically need more intensive blood pressure lowering.  On the other hand, if they have impaired regulation of cerebral blood flow, they might be harmed by rapid drops in blood pressure, and maybe we have to be more careful with them.

To answer this, we performed a subgroup analysis of the multi-centre ATACH-2 clinical trial of intensive blood pressure lowering. This was the first study to assess the effect of randomized acute stroke treatment on patients with more severe SVD, manifested by microbleeds.  We found that no matter what your small vessel disease burden on MRI, you’ll respond the same to early blood pressure management.

MedicalResearch.com: What should readers take away from your report?

Response: In acute acute intracerebral hemorrhage, patients with more severe small vessel disease don’t specifically benefit from intensive BP lowering. However, they also aren’t specifically harmed, so intensive blood pressure lowering seems safe even in this patient population.

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: Due to the early termination of the parent ATACH-2 trial, our analyses were likely underpowered to definitively answer our question.  Statistically insignificant trends of our point effect estimates did suggest that there may be a real effect under there – in that patients with microbleeds might in fact have less hematoma growth if their systolic blood pressure is acutely lowered. In the future, an adequately powered trial in this subgroup could more confidently answer this question. 

Any disclosures?

Dr Shoamanesh is supported by the McMaster University Marta and Owen Boris Chair in Stroke Research and Care


Shoamanesh A, Morotti A, Romero JM, et al. Cerebral Microbleeds and the Effect of Intensive Blood Pressure Reduction on Hematoma Expansion and Functional OutcomesA Secondary Analysis of the ATACH-2 Randomized Clinical TrialJAMA Neurol. Published online April 16, 2018. doi:10.1001/jamaneurol.2018.0454

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Last Updated on April 16, 2018 by Marie Benz MD FAAD