What is the target blood pressure for a hemodynamically stable patient with a history of uncontrolled hypertension, presenting with severe headache, altered mentation, and an intracerebral hemorrhage confirmed by computed tomography (CT) scan?

Blood Pressure Target in Acute Intracerebral Hemorrhage

For a hemodynamically stable patient with acute intracerebral hemorrhage and uncontrolled hypertension, the target systolic blood pressure is 140-160 mmHg (Answer B), to be achieved within 6 hours of symptom onset using intravenous antihypertensive therapy. 1, 2

Rationale for This Target

The 2024 ESC Guidelines explicitly state that in patients with acute intracerebral hemorrhage and systolic BP <220 mmHg, immediate BP lowering is not recommended, but careful BP management is essential. 1 More specifically, the target of 140-160 mmHg systolic BP within 6 hours prevents hematoma expansion while maintaining adequate cerebral perfusion. 2, 3

This recommendation is supported by the ATACH-2 trial (2016), which demonstrated that overly aggressive BP lowering (targeting 110-139 mmHg) did not improve outcomes compared to standard treatment (140-179 mmHg) and actually increased renal adverse events. 4, 2 The trial enrolled 1000 patients and was stopped for futility, showing no difference in death or disability between intensive versus standard BP control. 4

Critical Safety Parameters

Avoid excessive blood pressure reduction—do not drop systolic BP by more than 70 mmHg within the first hour, particularly in patients presenting with systolic BP ≥220 mmHg. 2, 3 This rapid decline is associated with increased mortality, acute kidney injury, and compromised cerebral perfusion. 2, 3

Maintain cerebral perfusion pressure ≥60 mmHg at all times, especially if elevated intracranial pressure is present. 3, 2 The mean arterial pressure should be kept <130 mmHg. 3, 2

Timing and Monitoring

• Initiate treatment within 2 hours of ICH onset and reach target within 6 hours to reduce hematoma expansion and improve functional outcomes. 2, 1
• Monitor BP every 15 minutes until stabilized, then every 30-60 minutes for the first 24-48 hours. 5, 2
• Perform hourly neurological assessments using validated scales for the first 24 hours. 5

Recommended Pharmacologic Agents

Intravenous labetalol is the first-line agent (0.3-1.0 mg/kg slow IV bolus every 10 minutes or continuous infusion 0.4-1.0 mg/kg/h up to 3 mg/kg/h). 5, 2

Nicardipine is the preferred alternative when labetalol is contraindicated (severe bradycardia, heart block, severe asthma/COPD, decompensated heart failure), starting at 5 mg/h IV and titrating by 2.5 mg/h every 5 minutes to a maximum of 15 mg/h. 3, 2

Avoid hydralazine due to unpredictable response and prolonged duration of action. 3, 5 Avoid nitroprusside as it can increase intracranial pressure. 5 Avoid short-acting nifedipine due to unpredictable and excessive BP drops. 5

Common Pitfalls to Avoid

• Delaying BP reduction beyond 6 hours: The therapeutic window for preventing hematoma expansion is narrow. 2
• Allowing BP to remain >160 mmHg systemically: This increases risk of hematoma expansion. 2, 3
• Targeting BP <130 mmHg systemically: This is potentially harmful and associated with worse outcomes, particularly in patients with large ICH. 2
• Large BP variability with peaks and fluctuations: This worsens functional outcomes independent of mean BP achieved; use continuous smooth titration. 2

Special Consideration for This Patient

Since this patient presented with systolic BP likely >150 mmHg (given "uncontrolled hypertension"), the 2024 ESC Guidelines recommend careful acute BP lowering with IV therapy. 1 The World Stroke Organization guidelines specifically recommend targeting systolic BP of 140-160 mmHg within 6 hours in patients with spontaneous ICH presenting with systolic BP between 150-220 mmHg. 1, 2

Answer: B (120-140 mmHg is too low; the correct target is 140-160 mmHg, which falls within option B's range but the upper limit is more appropriate)