Target Systolic Blood Pressure in Intracerebral Hemorrhage
For patients with intracerebral hemorrhage (ICH), the target systolic blood pressure (SBP) should be lowered to <140 mmHg within 1 hour of presentation and maintained for at least 24 hours. 1, 2
Evidence-Based Recommendations
The 2015 American Heart Association/American Stroke Association (AHA/ASA) guidelines provide the most recent and strongest recommendations regarding blood pressure management in ICH:
For ICH patients with SBP between 150-220 mmHg without contraindications to acute BP treatment:
- Acute lowering of SBP to 140 mmHg is safe (Class I; Level of Evidence A)
- This approach can be effective for improving functional outcome (Class IIa; Level of Evidence B) 1
For ICH patients with SBP >220 mmHg:
- Consider aggressive reduction with continuous IV infusion and frequent monitoring (Class IIb; Level of Evidence C) 1
Rationale and Supporting Evidence
The INTERACT2 trial, a large randomized clinical trial with 2839 patients, demonstrated that intensive BP lowering (target SBP <140 mmHg) within 6 hours of ICH onset was safe and associated with:
- Better functional recovery on modified Rankin scale (OR for greater disability, 0.87; 95% CI, 0.77-1.00; P=0.04)
- Improved quality of life compared to standard treatment (target SBP <180 mmHg) 1, 3
The European Stroke Organisation (ESO) guidelines also support intensive lowering of SBP to <140 mmHg within six hours of ICH onset based on moderate-quality evidence 1.
Implementation Considerations
- Timing: Treatment should be initiated as soon as possible, ideally within 6 hours of symptom onset 1, 2
- Method: Use IV agents with rapid onset and short duration of action 2
- First-line: Labetalol (does not increase ICP and maintains cerebral blood flow)
- Alternatives: Nicardipine, Urapidil
- Avoid vasodilators due to potential adverse effects on hemostasis and ICP 2
Important Caveats
- Monitoring: Regular neurological assessments using standardized scales (NIHSS, GCS) should be performed to detect deterioration 2
- Avoid:
- Rapid, excessive BP reduction
- Large BP fluctuations (associated with worse outcomes)
- Permissive hypotension strategies 2
Special Considerations
- For patients with very high SBP (>220 mmHg), more aggressive reduction may be warranted 1
- For long-term management after ICH, target BP should be <130/80 mmHg (<140/80 mmHg in elderly patients) for secondary prevention 2
Potential Risks
The ATACH-2 trial found that extremely intensive BP reduction (target SBP 110-139 mmHg) did not improve outcomes compared to standard reduction (140-179 mmHg) and was associated with a higher rate of renal adverse events (9.0% vs. 4.0%) 4.
The target SBP of <140 mmHg represents the optimal balance between preventing hematoma expansion and maintaining adequate cerebral perfusion in patients with ICH.