Clevidipine for the Antihypertensive Treatment of Acute Intracerebral Hemorrhage

Prior treatment

• Previously known neoplasms, arteriovenous malformation (AVM), or aneurysms.
• Subject considered a candidate for immediate surgical intervention by the neurosurgery service.
• Pregnancy, parturition within previous 30 days, or active lactation.

Other illness

• Any history of bleeding diathesis or coagulopathy except anticoagulant related ICH.
• Patients with allergies to soybeans, soy products, eggs, or egg products.

Lab values

• Platelet count of less than 50,000/mm3.

Other

• Time of symptom onset cannot be reliably assessed.
• Intracerebral hematoma considered to be related to trauma.
• ICH located in infratentorial regions such as pons or midbrain (cerebellar ICH is not an exclusion criteria).
• Known sensitivity to nicardipine or clevidipine.
• Patient's living will precludes aggressive ICU management.
• Defective lipid metabolism such as pathologic hyperlipemia, lipoid nephrosis, or acute pancreatitis if it is accompanied by hyperlipidemia.
• Patients with severe aortic stenosis.

• Age 18 years or older and less than 100 years.
• Onset of new neurological deficits within 12 hours at the time of enrollment and IV clevidipine or alternate IV antihypertensive regimen can be initiated within 12 hours of symptom onset.
• Clinical signs consistent with the diagnosis of stroke, including impairment of language, motor function, cognition, and/or gaze, vision, or neglect.
• Initial National Institutes of Health Stroke Scale (NIHSS) score of 1 or greater.
• Total GCS score (aggregate of verbal, eye, and motor response scores) of 5 or greater at enrollment
• Computed Tomography (CT) scan of the brain demonstrates intraparenchymal hematoma with manual hematoma volume measurement \>5 cc (excluding microhemorrhages)
• Admission SBP greater than and equal to 150 mmHg but less than 220 mmHg on two repeat measurements at least 5 minutes apart, but no more than 10 minutes apart. The reason for exclusion of ICH patients with initial SBP ≥220 mm Hg is based on a post hoc analysis of ATACH-2, which found that patients with initial SBP ≥220 mm Hg (22.8% of the cohort) reported higher rates of neurological deterioration at 24 hours and renal adverse events until day 7 or discharge in patients treated with intensive SBP reduction compared with standard SBP lowering, without any benefit in reducing hematoma expansion at 24 hours or death or severe disability at 90 days.
• Signed and dated informed consent by subject, legally authorized representative, or surrogate before index hospital discharge for data collection and agreement to participate in 90- and 180-day follow-up visits.
• Patients with anticoagulant-related ICH are eligible as long as anticoagulant reversal is concurrently undertaken consistent with AHA/ASA guidelines.
• Patients who will undergo surgical evacuation consistent with AHA/ASA guidelines or local institutional guidelines are eligible unless surgical evacuation is being performed within 6 hours of initiation of IV clevidipine or alternate IV antihypertensive medication regimen. Ultra-early surgery will necessitate use of anesthetic agents which will confound the effect of IV clevidipine or alternate IV antihypertensive medication regimen. Ultra-early surgery/intervention was not used in the minimally invasive catheter evacuation followed by thrombolysis (MISTIE)/ Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) trials, which required ICH patients to undergo a repeat CT scan after 6 hours to document absence of any hematoma expansion (with ≤5 mL hematoma growth) compared to a previous CT scan prior to any surgical intervention.
• Patients requiring external ventricular drainage consistent with AHA/ASA guidelines or local institutional guidelines are eligible.