• Mohamed Ridha, Murad Megjhani, Daniel Nametz, Soon Bin Kwon, Angela Velazquez, Shivani Ghoshal, Sachin Agarwal, Jan Claassen, David J Roh, Sander ConnollyEEJrNewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA.Department of Neurosurgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA., and Soojin Park.
• Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA. mrr2195@cumc.columbia.edu.
• Neurocrit Care. 2024 Jun 1; 40 (3): 9961005996-1005.

BackgroundRemote ischemic lesions on diffusion-weighted imaging (DWI) occur in one third of patients with intracerebral hemorrhage (ICH) and are associated with worse outcomes. The etiology is unclear and not solely due to blood pressure reduction. We hypothesized that impaired cerebrovascular autoregulation and hypoperfusion below individualized lower limits of autoregulation are associated with the presence of DWI lesions.MethodsThis was a retrospective, single-center study of all primary ICH with intraparenchymal pressure monitoring within 10 days from onset and subsequent magnetic resonance imaging. Pressure reactivity index was calculated as the correlation coefficient between mean arterial pressure and intracranial pressure. Optimal cerebral perfusion pressure (CPPopt) is the cerebral perfusion pressure (CPP) with the lowest corresponding pressure reactivity index. The difference between CPP and CPPopt, time spent below the lower limit of autoregulation (LLA), and time spent above the upper limit of autoregulation (ULA) were calculated by using mean hourly physiologic data. Univariate associations between physiologic parameters and DWI lesions were analyzed by using binary logistic regression.ResultsA total of 505 h of artifact-free data from seven patients without DWI lesions and 479 h from six patients with DWI lesions were analyzed. Patients with DWI lesions had higher intracranial pressure (17.50 vs. 10.92 mm Hg; odds ratio 1.14, confidence interval 1.01-1.29) but no difference in mean arterial pressure or CPP compared with patients without DWI lesions. The presence of DWI lesions was significantly associated with a greater percentage of time spent below the LLA (49.85% vs. 14.70%, odds ratio 5.77, confidence interval 1.88-17.75). No significant association was demonstrated between CPPopt, the difference between CPP and CPPopt, ULA, LLA, or time spent above the ULA between groups.ConclusionsBlood pressure reduction below the LLA is associated with ischemia after acute ICH. Individualized, autoregulation-informed targets for blood pressure reduction may provide a novel paradigm in acute management of ICH and require further study.© 2023. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.

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