Study Design: multi-centre randomized open-label, blinded-endpoint trial of two different
BP management strategies. This study is being conducted in the Emergency Departments and
Stroke Units of Canadian academic and non-academic centres.
Overall Aim and Hypothesis: The primary study aim is to assess the rate of ischemic
lesion development in patients randomized to two different BP treatment strategies. The
overall a priori hypothesis is that aggressive BP reduction will not be associated with
ischemic injury after ICH.
Patients: Male and female patients will be recruited from Emergency Departments of
participating hospitals. A total of 270 patients will be included over 3 years.
Baseline Data and Randomization: Demographics, Glasgow Coma Scale (GCS) and National
Institutes of Health Stroke Scale (NIHSS) scores (both of which are part of routine
stroke patient assessment), time of symptom onset and diagnostic CT scan will all be
recorded. If the CT scan is completed within 6 hours of onset and confirms evidence of a
primary ICH, patients will be randomized. Where patients are incompetent and surrogate
decision makers are not immediately available, randomization will occur using a deferred
consent procedure. Stroke risk factors, past medical history and medications, with
emphasis on antihypertensives, as well as standard clinical blood work (complete blood
count and coagulation profile) will be recorded after randomization in order to avoid
delays to BP treatment.
Intervention - Blood Pressure Management Protocols:
"Aggressive" BP Target (<140 mmHg) Treatment Group: Patients randomized to the <140 mmHg
group (n=135) will immediately receive a 10 mg IV bolus of labetalol, administered over 1
minute. A protocol designed to achieve and maintain systolic BP <140 mmHg within 60
minutes of randomization has been designed (Appendix 5). A key feature of this protocol
is the utilization of IV enalapril, which can be given regularly (Q. 6 hourly), avoiding
BP fluctuations, a problem which has been noted previously when using bolus-based
protocols.109 Patients randomized to the <140 mmHg group will be treated with 1.25 mg of
IV enalapril immediately after labetalol administration. A lower limit of 120 mmHg has
been stipulated, although given the investigators experience in ICH ADAPT I, this is
unlikely to be achieved. In the event of systolic BP falling below 120 mmHg,
antihypertensive therapy will be held and patients will be fluid resuscitated with
isotonic saline. Pressor agents will not be used.
"Conservative" BP Target (<180 mmHg) Treatment Group: Patients randomized to the <180
mmHg group (n=135) will be administered parenteral antihypertensive therapy only if
systolic BP is ≥180 mmHg, consistent with current guidelines.
All patients will have continuous non-invasive BP and heart rate (HR) monitoring for a
minimum of 24h. BP and HR will be recorded most intensively during the hyperacute phase,
as per the NINDS r-tPA protocol for vital signs monitoring. Antihypertensive drug use and
dosages will be recorded concomitantly with BP and HR. Patients will be monitored
regularly until study completion. Door-to-needle times will be documented with respect to
the initiation of antihypertensive medication and the proportion of patients achieving BP
targets within 1 hour of treatment.
At completion of the 24h active treatment period, all patients will continue to receive
standard stroke care and rehabilitation, and treating physicians will manage BP in the
manner they feel is appropriate. Physicians will be encouraged to start oral
antihypertensive therapy, administered via nasogastric feeding tube if necessary, on day
2. BP, HR and antihypertensive medication doses will continue to be monitored and
recorded every 4 h for the first 48 h and then twice daily until discharge. Long-term
goals for both patient groups after the active treatment period are a systolic BP of <140
mmHg, or <130 mmHg in those with diabetes, as per current stroke prevention and
hypertension guidelines.
Imaging Procedures:
Baseline - Immediately prior to randomization and BP reduction, patients will undergo a
standard non-contrast CT diagnostic brain scan. In the event of early neurological
deterioration at any point, a repeat CT scan will be obtained immediately.
24 hour CT - All patients will have a repeat CT brain scan at 24±3 h, in order to assess
for hematoma expansion and peri-hematoma edema volume.
48 hour MRI - At 48±12 h, patients will undergo MRI scanning, including a T1-weighted
sagittal localizer, DWI, Gradient Recalled Echo (GRE)/Susceptibility Weighted Imaging
(SWI), diffusion-weighted (DWI) and perfusion-weighted images (PWI).
Day 7 MRI Scan (Secondary Endpoint) - A repeat MRI will be obtained at 7±2 days to assess
for new DWI lesion development and evolution of those identified at 24 hours.
Day 30 MRI Scan (Secondary Endpoint) - A repeat MRI will be obtained at 30±5 days to
assess for new DWI lesion development and evolution of those identified at 24 hours and 7
days.
Clinical Assessments:
In Hospital - In addition to BP data, GCS and NIHSS scores will be collected in the event
of early neurological deterioration. Both of these scores will also be recorded at the
time of each MRI scan and at hospital discharge or transfer to alternate level of care,
i.e. rehabilitation or long-term care facility. Discharge modified Rankin Scores (mRS)
will also be recorded. Cognitive changes will be assessed with the Montreal Cognitive
Assessment (MoCA) at the time of each MRI scan.
Follow-up (Day 30) - A standardized interview aimed at determining mortality and current
residence of the patient (home/hospital/rehabilitation hospital/long-term care facility)
will be administered at the time of the day 30 MRI. The NIHSS and MoCA scores will also
be recorded, as will modified Rankin scale (mRS) scores. Quality of life will be assessed
with the EQ-5D.
(Day 90) - This is the standard time point for measuring functional outcomes in stroke
trials, as the bulk of neurological recovery occurs within that time frame. All
neurological, functional and cognitive disability tests will be repeated at this time.