In an adult with acute intracerebral or subarachnoid hemorrhage and a presenting systolic blood pressure of 150–220 mmHg, what is the target blood pressure and the recommended first‑line antihypertensive agents?

Blood Pressure Management After Intracerebral and Subarachnoid Hemorrhage

Intracerebral Hemorrhage (ICH)

For adults with acute ICH presenting with systolic BP 150–220 mmHg, target a systolic BP of 140 mmHg (acceptable range 130–150 mmHg) and achieve this within 1 hour of treatment initiation, using intravenous nicardipine as the first-line agent. 1

Target Blood Pressure

• Systolic BP target: 140 mmHg (range 130–150 mmHg) to be reached within the first hour of therapy initiation 1
• Treatment must be started within 2 hours of symptom onset and all BP goals achieved within 6 hours of hemorrhage onset to prevent hematoma expansion 1, 2
• Never lower systolic BP below 130 mmHg—this carries a Class III: Harm recommendation and is associated with worse neurological outcomes and higher mortality 1
• Maintain cerebral perfusion pressure (CPP) ≥60 mmHg at all times, especially when intracranial pressure is elevated 1, 2

First-Line Antihypertensive Agent

Intravenous nicardipine is the preferred first-line agent because it allows precise titration, provides sustained BP control, maintains cerebral blood flow, and does not raise intracranial pressure 1

Nicardipine Dosing Protocol

• Start at 5 mg/hour IV infusion 1
• Titrate by increasing 2.5 mg/hour every 5 minutes to a maximum of 15 mg/hour until target BP is achieved 1
• Continuous smooth titration is mandatory to minimize BP variability, which independently worsens functional outcomes 1

Alternative Agent: Labetalol

• Use when nicardipine is contraindicated (severe bradycardia, heart block, severe asthma/COPD, decompensated heart failure) 1
• Dosing: 5–20 mg IV bolus every 15 minutes or continuous infusion at 2 mg/min 3
• Labetalol preserves cerebral blood flow and does not increase intracranial pressure 3

Critical Safety Parameters

• Avoid dropping systolic BP by more than 70 mmHg within the first hour, particularly in patients presenting with systolic BP ≥220 mmHg, as this increases risk of acute kidney injury and neurological deterioration 1, 2
• Never use glyceryl trinitrate (GTN) in acute ICH—the RIGHT-2 trial showed GTN was associated with greater hematoma growth and poorer outcomes 4
• Avoid sodium nitroprusside and other venous vasodilators as they may increase intracranial pressure and promote hematoma growth 3, 5

Monitoring Requirements

• Continuous arterial line monitoring is mandatory for patients receiving continuous IV antihypertensives—automated cuff measurements are insufficient 1, 3
• Measure BP every 15 minutes until target is reached, then every 30–60 minutes for the first 24–48 hours 1
• Perform hourly neurological assessments (NIHSS, Glasgow Coma Scale) during the first 24 hours 1
• Minimize BP variability during the first 24 hours, as large fluctuations independently worsen functional outcomes even when mean BP is within target 1

Special Populations: Large or Severe ICH

• In patients with large hemorrhages or those requiring surgical decompression, the safety of intensive BP lowering is uncertain 1
• Accept slightly higher systemic BP targets (up to 160 mmHg) if intracranial pressure is markedly elevated, provided CPP remains ≥60 mmHg 1
• Consider ICP monitoring in cases of multicompartmental hemorrhage with neurological decline to guide individualized BP management 1

Common Pitfalls to Avoid

• Delaying antihypertensive treatment beyond 2 hours from symptom onset narrows the therapeutic window for preventing hematoma expansion 1
• Allowing systemic systolic BP to remain >160 mmHg increases the risk of hematoma expansion 1
• Using unpredictable formulations (sublingual, immediate-release, or rectal antihypertensives) can cause abrupt BP falls and worsen outcomes 1
• Permitting large BP variability during titration worsens functional outcomes independent of mean BP achieved 1

---

Subarachnoid Hemorrhage (SAH)

For adults with acute aneurysmal SAH, maintain systolic BP <160 mmHg (European guidelines) or <180 mmHg (American guidelines) using titratable agents, with analgesics and nimodipine as initial therapy, while ensuring mean arterial pressure >90 mmHg. 4

Target Blood Pressure

• European Stroke Organization guideline: Treat if systolic BP exceeds 180 mmHg, maintaining mean arterial pressure >90 mmHg 4
• American Heart Association/American Stroke Association guideline: Treat with a titratable agent if systolic BP exceeds 160 mmHg 4
• The goal is to prevent aneurysm re-bleeding while avoiding delayed cerebral ischemia (DCI) 4

First-Line Agents

• Start with analgesics and nimodipine as initial therapy 4
• Use titratable IV agents (nicardipine or labetalol) as necessary to maintain target BP 4, 2
• Nicardipine: 5 mg/hour IV, titrate by 2.5 mg/hour every 5–15 minutes up to 15 mg/hour 2
• Labetalol: 10–20 mg IV bolus over 1–2 minutes, repeat or double every 10 minutes (maximum 300 mg cumulative) 2

Monitoring and Safety

• Maintain mean arterial pressure >90 mmHg to prevent cerebral hypoperfusion 4
• Balance the risk of re-bleeding (favored by high BP) against the risk of delayed cerebral ischemia (worsened by low BP) 4
• Continuous arterial line monitoring is recommended for precise BP control 2

Evidence Gaps

• An RCT is needed to definitively establish optimal BP targets in SAH, as current recommendations are based on observational data and expert consensus 4
• The dichotomy between preventing re-bleeding and avoiding DCI remains unresolved 4