Blood Pressure Control in Intracranial Hemorrhage

A summary of recommendations from the 2012 American Stroke Association guidelines on intracranial hemorrhage

Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence. Current suggested recommendations for target BP in various situations are listed below and may be considered Class IIb (Level of Evidence: C) unless otherwise noted.

• In patients presenting with a systolic BP of 150 to 220 mmHg, acute lowering of systolic BP to 140 mm Hg is probably safe (Class IIa; Level of Evidence: B). (New recommendation)
• If SBP is >200 mm Hg or MAP is >150 mm Hg, then consider aggressive reduction of BP with continuous intravenous infusion, with frequent BP monitoring every 5 min.
• If SBP is >180 mmHg or MAP is >130mm Hg and there is the possibility of elevated ICP, then consider monitoring ICP and reducing BP using intermittent or continuous intravenous medications while maintaining a cerebral perfusion pressure >60 mm Hg.
• If SBP is >180 mmHg or MAP is >130 mmHg and there is not evidence of elevated ICP, then consider a modest reduction of BP (eg, MAP of 110 mm Hg or target BP of 160/90 mm Hg) using intermittent or continuous intravenous medications to control BP and clinically reexamine the patient every 15 min.

Latest publication on BP control in ICH:

The INERACT2 trial (see references). Showed aggressive BP management (target systolic <140) was associated with improved neurologic outcomes by Rankin score. No mortality difference. Lots of patients not in US (China) and multiple different anti-hypertensive agents used. Original INTERACT trial showed aggressive BP management associated with decreased hematoma expansion. Next big publication should be the ATACH-II trial which is going to be cool because all patients will get one agent to control BP… and a good one -> nicardipine drip.

Summary:

• BP control in intracranial hemorrhage:
  • Goal systolic BP < 160 mm Hg and be aggressive. It’s “probably” safe to even go < 140 mm Hg.
• Other Neuro BP goals:
  • Ischemic stroke tPA candidate: BP < 185/110 mm Hg
  • Once tPA started for tx ischemic stroke, maintain BP ≤ 180/105 mm Hg

References:

1. In intracerebral hemorrhage, rapid blood pressure reductions were safe (INTERACT2) - PulmCCM. (n.d.). http://pulmccm.org/2013/randomized-controlled-trials/in-intracerebral-hemorrhage-rapid-blood-pressure-reductions-were-safe-interact2/
2. Anderson, C. S., Heeley, E., Huang, Y., Wang, J., Stapf, C., Delcourt, C., … Chalmers, J. (2013). Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage. New England Journal of Medicine, 368(25), 2355–2365. doi:10.1056/NEJMoa1214609
3. Morgenstern, L. B., Hemphill, J. C., Anderson, C., Becker, K., Broderick, J. P., Connolly, E. S., … on behalf of the American Heart Association Stroke Council and Council on Cardiovascular Nursing. (2010). Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, 41(9), 2108–2129. doi:10.1161/STR.0b013e3181ec611b