White Matter Hyperintensities and Blood Pressure Lowering in Acute Intracerebral Hemorrhage: A Secondary Analysis of the ATACH-2 Trial

Background It is not clear whether subsets of patients with intracerebral hemorrhage (ICH) benefit from intensive blood pressure (BP) lowering. We evaluated whether white matter hyperintensities (WMH) burden influences response to this therapy. Methods Retrospective secondary analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial. Patients were randomized to intensive (systolic BP target: 110–139 mmHg) versus standard (systolic BP target: 140–179 mmHg) BP treatment with intravenous nicardipine within 4.5 h from onset between May 2011 and September 2015. WMH were rated on magnetic resonance images (fluid-attenuated inversion recovery sequences), defining moderate–severe WMH as total Fazekas scale score ≥ 3 (range 0–6). The main outcome was death or major disability at 90 days (modified Rankin scale ≥ 3). The secondary outcome was ICH expansion, defined as hematoma growth > 33% from baseline to follow-up CT scan. Predictors of the outcomes of interest were explored with multivariable logistic regression. Results A total of 195/1000 patients had MRI images available for analysis, of whom 161 (82.6%) had moderate–severe WMH. When compared to patients with none–mild WMH, those with moderate–severe WMH did not have an increased risk of death or major disability (adjusted relative risk: 1.83, 95% CI 0.71–4.69) or ICH expansion (adjusted relative risk: 1.14, 95% CI 0.38–3.37). WMH burden did not modify the effect of intensive BP treatment on outcome (all p for interaction ≥ 0.2). Conclusion The majority of acute ICH patients have moderate–severe WMH, but advanced small vessel disease burden marked by WMH does not influence ICH-related outcomes or response to intensive BP reduction.