What is the target mean arterial pressure (MAP) for acute intracerebral hemorrhage (ICH)?

Target MAP for Acute Intracerebral Hemorrhage

In patients with intracerebral hemorrhage, blood pressure should be immediately lowered (within 6 hours of symptom onset) to a systolic target of 140-160 mmHg to prevent hematoma expansion and improve functional outcome. 1

Blood Pressure Management Guidelines for ICH

• For patients with spontaneous ICH presenting within 6 hours of symptom onset, intensive blood pressure reduction with a systolic target of 140-160 mmHg is recommended 1
• Blood pressure lowering should be initiated within 2 hours of ICH onset and reach target within 1 hour to effectively reduce the risk of hematoma expansion 2, 3
• Systolic blood pressure should not be lowered below 130 mmHg as this may compromise cerebral perfusion and is potentially harmful 2, 3, 4
• For patients with very high systolic BP (≥220 mmHg), acute reduction in systolic BP >70 mmHg from initial levels within 1 hour of treatment is not recommended due to risk of neurological deterioration 1, 5
• Cerebral perfusion pressure (CPP) should be maintained >60 mmHg to prevent cerebral hypoperfusion 1, 3

Medication Selection for BP Management

• First-line agents for acute BP management in ICH include labetalol and nicardipine, which have reliable dose-response relationships and safety profiles 2, 3
• Labetalol is preferred for patients with tachycardia (5-20 mg IV bolus every 15 minutes or continuous infusion at 2 mg/min) 2, 3
• Nicardipine is preferred for patients with bradycardia, heart failure, or bronchospasm (starting at 5 mg/hour IV infusion) 2, 3, 6
• Avoid venous vasodilators like nitroprusside as they may have negative effects on hemostasis and intracranial pressure 3

Evidence Supporting BP Targets

• The INTERACT-2 trial demonstrated that intensive blood pressure reduction (systolic target <140 mmHg) was safe and associated with improved functional outcomes compared to a standard target (<180 mmHg) 1
• The ATACH-2 trial showed that more aggressive BP lowering (systolic 110-139 mmHg) did not provide additional benefit over standard reduction (140-179 mmHg) and was associated with higher rates of renal adverse events 5
• A prospective multicenter study (SAMURAI-ICH) found that lowering systolic BP to ≤160 mmHg using nicardipine was well tolerated with low rates of neurological deterioration (8.1%) 6
• Recent evidence suggests that acute BP intervention to a systolic target of approximately 140 mmHg appears beneficial, particularly when combined with other critical care interventions 4

Monitoring Recommendations

• Continuous blood pressure monitoring is recommended for patients requiring IV antihypertensive medications 2
• Frequent BP checks are needed to avoid large fluctuations that could lead to neurological deterioration 2, 3
• For patients with evidence of elevated intracranial pressure (ICP), consider ICP monitoring and maintain cerebral perfusion pressure at 60-80 mmHg 3

Common Pitfalls to Avoid

• Excessive acute drops in systolic BP (>70 mmHg) may cause acute renal injury and early neurological deterioration 1, 5
• Delaying BP management beyond 6 hours of symptom onset may reduce effectiveness in preventing hematoma expansion 1, 4
• Lowering systolic BP below 130 mmHg may compromise cerebral perfusion and worsen outcomes 2, 3, 5
• Failing to adjust BP targets in patients with chronic hypertension who may have altered cerebral autoregulation 1

In summary, the current evidence supports maintaining MAP around 93-107 mmHg (corresponding to systolic BP 140-160 mmHg) in acute ICH, with careful attention to avoid excessive BP reduction that could compromise cerebral perfusion.