From the Guidelines
The target blood pressure for traumatic intracranial hypertension (ICH) should be systolic blood pressure ≤ 180 mm Hg and/or mean arterial pressure < 130 mm Hg to maintain cerebral perfusion pressure (CPP) > 60 mm Hg.
Rationale
- The evidence suggests that overaggressive treatment of blood pressure may decrease CPP and worsen brain injury, particularly in the setting of increased ICP 1.
- A prospective observational study found that reduction of systolic blood pressure to a target < 160/90 mm Hg was associated with neurological deterioration in 7% of patients and with hemorrhagic expansion in 9% 1.
- Experience in traumatic brain hemorrhage, as well as spontaneous ICH, supports preservation of the CPP > 60 mm Hg 1.
- The American Heart Association/American Stroke Association guidelines recommend maintaining a systolic blood pressure ≤ 180 mm Hg and/or mean arterial pressure < 130 mm Hg 1.
Key Considerations
- CPP-guided therapy focuses on maintaining a CPP of 70 mm Hg to minimize reflex vasodilation or ischemia, but concern remains that blood pressure elevation to maintain CPP may advance intracranial hypertension 1.
- ICP monitoring is considered fundamental to the care of patients with ABI, particularly those in coma, and is routinely used to direct medical and surgical therapy 1.
- A balanced approach to ICP management makes use of simple and less aggressive measures, such as head positioning, analgesia, and sedation, and then progresses to more aggressive measures as clinically indicated 1.
From the Research
Target Blood Pressure for Traumatic Intracranial Hypertension
The optimal target blood pressure (BP) for traumatic intracranial hypertension (ICH) is still a topic of debate. Several studies have investigated this issue, but the results are not conclusive.
- A narrative review of existing literature, clinical guidelines, and emerging technologies proposed a comprehensive approach to defining and meeting continuous arterial blood pressure (ABP) and cerebral perfusion pressure (CPP) targets in the context of severe traumatic brain injury (TBI) 2.
- A review of guideline recommendations and literature for BP management in patients with ischemic stroke, intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, traumatic brain injury, and spinal cord injury found that optimal BP management is controversial in neurocritically ill patients due to conflicting concerns 3.
- A study of stable patients with acute isolated blunt traumatic intracranial hemorrhage (TICH) found that a comprehensive dynamic analysis correlating repeated BP determinations with quantifiable repeated parameters of TICH deterioration did not demonstrate a clinically relevant protective target BP value 4.
- A systematic review and meta-analysis of randomized controlled trials found that intensive BP lowering compared to standard BP treatment in acute spontaneous ICH did not result in significant differences in 3-month mortality, disability, or combined death and disability 5.
- A retrospective study of patients with spontaneous intracerebral hemorrhage (sICH) monitored with an external ventricular drain (EVD) found an association between intracranial pressure variability (ICPV) and hematoma expansion, but the relationship between blood pressure variability (BPV) and outcomes was less clear 6.
Key Findings
- There is no clear consensus on the optimal target BP for traumatic ICH.
- BP management in neurocritically ill patients is controversial due to conflicting concerns.
- Intensive BP lowering may not be beneficial in acute spontaneous ICH.
- ICPV may be associated with hematoma expansion in patients with sICH.
- Further research is needed to determine the optimal target BP for traumatic ICH and to understand the relationship between BPV and outcomes in patients with ICH.