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Blood Pressure Management in Intracranial Hemorrhage: Current Challenges and Opportunities
Cheryl Carcel1,2,3, Shoichiro Sato1, Craig S Anderson4,5,6,7
1Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia.
Insights
Intensive blood pressure lowering in intracerebral hemorrhage (ICH) improves outcomes and quality of life. Guidelines now favor aggressive BP management in ICH, unlike the less defined approach for subarachnoid hemorrhage (SAH).
Area of Science:
- Neurology
- Cardiovascular Medicine
- Critical Care Medicine
Background:
- Non-traumatic intracranial hemorrhage, including intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), presents significant life-threatening challenges.
- Elevated blood pressure (BP) is a critical predictor of poor outcomes in both ICH and SAH patients.
Purpose of the Study:
- To evaluate the impact of intensive BP lowering therapy versus guideline-recommended therapy in patients with spontaneous ICH.
- To discuss the complexities and current understanding of BP management in SAH.
Main Methods:
- Analysis of data from the INTERACT 2 trial, involving 2839 participants with spontaneous ICH.
- Random assignment to intensive BP lowering (systolic BP <140 mmHg) or guideline-recommended BP lowering (systolic BP <180 mmHg) therapy.
Main Results:
- Intensive BP lowering in ICH was found to be safe.
- Survivors in the intensive treatment group demonstrated more favorable functional outcomes and improved health-related quality of life.
- Current guidelines for ICH management have shifted towards more aggressive early BP management.
Conclusions:
- Intensive BP lowering therapy offers significant benefits for patients with spontaneous intracerebral hemorrhage.
- Blood pressure management in subarachnoid hemorrhage remains complex, with established benefits for hypertension control in the acute phase but questionable benefits of induced hypertension later.
Opinion Statement:
Non-traumatic intracranial hemorrhage (i.e. intracerebral hemorrhage [ICH] and subarachnoid hemorrhage [SAH]) are more life threatening and least treatable despite being less common than ischemic stroke. Elevated blood pressure (BP) is a strong predictor of poor outcome in both ICH and SAH. Data from a landmark clinical trial INTERACT 2, wherein 2839 participants enrolled with spontaneous ICH were randomly assigned to receive intensive (target systolic BP <140 mmHg) or guideline recommended BP lowering therapy (target systolic BP <180 mmHg), showed that intensive BP lowering was safe, and more favorable functional outcome and better overall health-related quality of life were seen in survivors in the intensive treatment group. These results contributed to the shift in European and American guidelines towards more aggressive early management of elevated BP in ICH. In contrast, the treatment of BP in SAH is less well defined and more complex. Although there is consensus that hypertension needs to be controlled to prevent rebleeding in the acute setting, induced hypertension in the later stages of SAH has questionable benefits.
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