Aggressive Blood Pressure Lowering in Intracerebral Hemorrhage May Be Harmful

ICU monitor
ICU monitor
The avoidance of SBP

In patients with intracerebral hemorrhage (ICH), intensive lowering of systolic blood pressure (SBP) to <140 mm Hg, in particular allowing SBP <120 mm Hg, is associated with increased remote cerebral ischemic lesions and acute neurologic deterioration, according to the results of a retrospective review published in Neurology.

The investigators sought to compare the incidence of acute ischemic lesions in individuals with acute ICH 1 year before and after the institutional protocol change in SBP target from <160 mm Hg to <140 mm Hg and to understand the clinical significance of these ischemic lesions. A secondary objective of the study was to identify predictors of acute ischemic lesions in individuals with ICH.

Of 286 patients with primary ICH, a total of 119 underwent magnetic resonance imaging (MRI) and met study inclusion criteria. Overall, 62 individuals had a target SBP of <160 mm Hg (group 1) and 57 had a target SBP of <140 mm Hg (group 2). Although no differences were observed in the 2 groups with respect to baseline clinical and radiographic characteristics, over the first 24 hours of hospitalization group 2 exhibited significantly lower mean SBP compared with group 1 (134 mm Hg vs 143 mm Hg, respectively; P <.001) and significantly lower minimum SBP over 72 hours (106 mm Hg vs 112 mm Hg, respectively; P =.02).

The occurrence of acute cerebral ischemia was significantly more common in group 2 compared with group 1 (32% vs 16%, respectively; P =.047), as was the presence of neurologic deterioration (19% vs 5%, respectively; P =.022). A minimum SBP of ≤120 mm Hg over 72 hours was linked to cerebral ischemia, even though no patient with a minimum SBP ≥130 mm Hg exhibited cerebral ischemia. Acute cerebral ischemia was significantly associated with worse discharge National Institutes of Health (NIH) Stroke Scale score, whereas SBP target was not.

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The investigators concluded that aggressive BP lowering in patients with ICH can cause harm. The avoidance of SBP <120 mm Hg in individuals with acute ICH may help prevent cerebral ischemia and neurologic deterioration. It should be noted that study inclusion of only patients who underwent brain MRI limits the generalizability of the study findings, as 38% of patients were excluded from the study cohort for this reason.


Buletko AB, Thacker T, Cho SM, et al. Cerebral ischemia and deterioration with lower blood pressure target in intracerebral hemorrhage [published online August 10, 2018]. Neurology. doi:10.1212/WNL.0000000000006156