Intensive Blood Pressure Lowering in Intracerebral Hemorrhage
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A 55-year-old man presents within 2 hours of acute left-sided weakness. Head computed tomography reveals a 60 mL right thalamic hemorrhage. Blood pressure (BP) on presentation is 150/95 mm Hg.
Should BP be lowered? If yes, what is the target BP and which antihypertensive agents should be used?
Intensive BP Lowering in Intracerebral Hemorrhage
BP Should Be Lowered
As the on-call stroke neurologist, I would treat this patient according to an approved management of intracerebral hemorrhage (ICH) protocol readily available on the hospital intranet and my decision support tool. The patient is at high risk for poor outcome—early presentation, large hematoma, deep location—and early, rapid and sustained control of elevated systolic BP (SBP, target <140 mm Hg) has reasonably strong supporting evidence of benefit on functional outcome, without significant harm.1 Moreover, BP lowering is a component of active care, with avoidance of early do-not-resuscitate (or palliative care) orders.
I recognize that clinicians require level 1, or grade A, quality information from research that is scientifically robust, current, and closely matches the patients they encounter in routine practice. However, generating randomized evidence for decision-making in ICH is complex because of its low rate compared with acute ischemic stroke, heterogeneous causes, high early mortality, and variable involvement of neurosurgery.
Although the clinical association of high BP and adverse outcomes in ICH is common, there has been longstanding concern that rapid BP lowering can cause cerebral ischemia, especially if cerebral autoregulation is altered from chronic hypertension or brain injury. However, focused studies have not confirmed any such harm by showing no significant relationship between BP lowering and cerebral blood flow or oxygenation in the perihematomal region or cerebral hemispheres in ICH patients.2
Failure to provide a clear effect on the primary outcome of early intensive BP lowering compared with contemporaneous BP management (SBP <180 mm Hg) in 2839 …