From the Guidelines
The blood pressure goal for intracranial hemorrhage is to lower systolic BP to a target range of 130 to 140 mm Hg, as this is safe and may be reasonable in improving functional outcome in patients presenting with acute ICH of mild to moderate severity and SBP between 150 and 220 mm Hg. This recommendation is based on the latest guidelines from the American Heart Association/American Stroke Association, as outlined in the 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage 1.
Key Considerations
- Initiating treatment as soon as possible and careful titration of BP-lowering therapy to ensure continuous smooth and sustained control of BP are recommended.
- Acute lowering of SBP to <130 mm Hg in patients presenting with ICH and elevated BP is potentially harmful and should be avoided.
- The current recommendations are based on data from the 2 largest trials (INTERACT2 and ATACH-2) for early intensive BP lowering (EIBPL) after ICH, as well as meta-analyses and post hoc analyses of these trials 1.
Management Approach
- Blood pressure management should begin immediately upon diagnosis and continue through the acute phase of care.
- Frequent monitoring is essential, ideally with arterial line measurement in an ICU setting, to avoid excessive drops that could worsen outcomes.
- For patients presenting with severe hypertension (SBP > 220 mmHg), aggressive reduction with continuous IV infusions may be necessary, while for less severe elevations, intermittent IV medications or oral agents can be used.
From the Research
Blood Pressure Goals for Intracranial Hemorrhage
- The optimal blood pressure goal for patients with intracranial hemorrhage is a topic of ongoing research, with various studies suggesting different target ranges 2, 3, 4, 5.
- A study published in 2020 found that an initial systolic blood pressure between 120 and 150 mmHg is associated with minimal risk of mortality in patients with non-traumatic intracranial hemorrhage 2.
- Another study from 2019 suggested that a systolic blood pressure goal of less than 140 mmHg may be beneficial in reducing blood pressure variability and improving outcomes in patients with spontaneous intracerebral hemorrhage 3.
- The use of antihypertensive agents such as nicardipine, labetalol, and hydralazine has been studied in the context of intracranial hemorrhage, with varying results 6, 3, 4.
- A 2016 review of blood pressure management in intracranial hemorrhage highlighted the importance of controlling elevated blood pressure to prevent poor outcomes, but noted that the optimal treatment strategy is still unclear 5.
Target Blood Pressure Ranges
- Systolic blood pressure: 120-150 mmHg 2
- Systolic blood pressure: <140 mmHg 3
- Mean arterial pressure: 70-100 mmHg 2
- Diastolic blood pressure: 60-100 mmHg 2
Antihypertensive Agents
- Nicardipine: may reduce blood pressure variability and improve outcomes 3
- Labetalol: may be effective in controlling blood pressure, but may have varying effects on blood pressure variability 6, 3, 4
- Hydralazine: may have similar effects to labetalol on intracranial pressure, but may require more interventions for elevated ICP 6