Diastolic Blood Pressure Management in Acute Hemorrhagic Stroke
In acute hemorrhagic stroke (intracerebral hemorrhage), target a diastolic blood pressure <105 mmHg as part of achieving an overall systolic target of 140-160 mmHg, initiated within 6 hours of symptom onset to prevent hematoma expansion. 1
Primary Blood Pressure Targets for Hemorrhagic Stroke
The European Society of Cardiology recommends immediate blood pressure lowering (within 6 hours of symptom onset) to a systolic target of 140-160 mmHg in patients with intracerebral hemorrhage presenting with systolic BP ≥150 mmHg, which corresponds to maintaining diastolic BP <105 mmHg. 1
This aggressive approach differs fundamentally from ischemic stroke management because there is no penumbral tissue at risk in hemorrhagic stroke, making rapid BP reduction well-tolerated without risk of neurological worsening. 2
The primary goal is preventing hematoma expansion, which occurs most commonly in the first 6 hours and is directly related to elevated blood pressure. 3, 2
Critical Safety Thresholds
Avoid excessive acute drops in systolic BP >70 mmHg from initial levels within 1 hour of commencing treatment, as this increases risk of acute renal injury and early neurological deterioration. 1
For patients presenting with systolic BP ≥220 mmHg, the same systolic target of 140-160 mmHg applies, but the rate of reduction must be controlled to avoid precipitous drops. 1
Pharmacological Approach
Intravenous labetalol or nicardipine are the preferred agents for blood pressure control in acute hemorrhagic stroke, allowing for precise titration to avoid excessive drops. 1, 3
Labetalol dosing: 10-20 mg IV over 1-2 minutes, may repeat, or continuous infusion 2-8 mg/min. 4
Nicardipine dosing: 5 mg/h IV, titrate by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h. 4
Distinction from Ischemic Stroke Management
The blood pressure targets for hemorrhagic stroke are fundamentally opposite to ischemic stroke—hemorrhagic stroke requires active lowering to 140-160 mmHg systolic, while ischemic stroke typically maintains permissive hypertension up to 220/120 mmHg. 3
In ischemic stroke not receiving thrombolysis, diastolic BP is only treated if >120 mmHg, whereas in hemorrhagic stroke, active reduction begins at much lower thresholds. 1, 3
Timing Considerations
Treatment must be initiated within 6 hours of symptom onset to effectively reduce hematoma expansion and improve functional outcomes. 1, 3
Multiple trials have confirmed that rapid BP reduction within this window is safe and feasible, though the clinical benefit on functional outcomes remains modest. 2, 5
Common Pitfalls to Avoid
Do not apply ischemic stroke blood pressure management principles to hemorrhagic stroke—the two conditions require opposite approaches in the acute phase. 3
Do not delay treatment beyond 6 hours, as the opportunity to prevent hematoma expansion diminishes rapidly. 3
Do not reduce blood pressure too rapidly (>70 mmHg drop in systolic BP within 1 hour), as this increases risk of renal complications without additional benefit. 1, 2
Do not target systolic BP <140 mmHg, as trials have shown no additional benefit below this threshold and increased risk of renal complications. 2, 6