55 yoF h/o HTN presents BIBEMS with acute onset decreased level of consciousness, onset 3 hours prior to arrival.

BP 220/140 HR 50 T 98.0 RR 10 SPO2 92%.

Pt is obtunded, no localizing neuro findings.

Pt intubated for airway protection.

CT shows 30ml intracerebral hemorrhage.


What are your management goals for blood pressure?

Outcome in ICH is related to volume and subsequent growth of the hematoma.  Reversing coagulopathies and treating severe hypertension are clinical mainstays in this regard.   Addressing severe hypertension appears to mitigates hematoma growth, though this requires consideration of maintaining cerebral perfusion pressure in CVA management.  Optimal BP in ICH remains debated.

 In 2008, the INTERACT pilot trial randomized 400 patients with ICH to either strict BP control (<140 systolic) versus guideline based care (<180 systolic) with a primary endpoint of hematoma growth. The results suggested that strict BP control reduced hematoma growth, though this pilot data did not demonstrate any subsequent difference in clinically significant outcomes between the two groups.  

 INTERACT 2, published in 2013, subsequently randomized 2838 patients to the same interventions, and found that there was no mortality benefit or effect on significant disability (Rankin score of 3 to 6) with intensive blood pressure management.  Again, this dichotomous analysis, based on outcomes the authors, and us as clinicians, view as clinically important (significant disability or not, alive or not), did not demonstrate any benefit (or harms) to stricter BP control.  Interestingly, there was not any difference in hematoma growth between the two groups.  As secondary outcomes, Rankin scores were viewed in ordinal analysis, which associated incremental benefit in outcomes with strict BP management (more likely to have a lower score with strict BP control).  

 Notably, INTERACT 2 excluded comatose patients (GCS 3-5), and patients with a “massive” hematoma with a “poor prognosis”.   The median GCS of the study group was 14, and median hematoma size was 11ccs.  This group was not remarkably sick.  It is important to recognize that the majority of new data on ICH blood pressure control do not directly inform our care on the critically ill.


Back to our patient:

Based on this brief review of the literature, acutely in the ED, I would promptly lower the systolic BP <180, and subsequently consult with neurosurgical and neurology colleagues on further care of the patient.  The tone of the literature leads me to suspect that our colleagues upstairs will push for lower BP, which given the most recent data, doesn’t seem harmful, and may be in accordance with their departmental expectations, but any push for strict BP management in ICH is not grounded in randomized trial data.

Of note, the North American Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH-II ) is ongoing, randomizing a goal of 1200 patient into strict vs standard BP control with nicardipine.

Anderson CS, Huang Y, Wang JG, Arima H, Neal B, Peng B, Heeley E, Skulina C,
Parsons MW, Kim JS, Tao QL, Li YC, Jiang JD, Tai LW, Zhang JL, Xu E, Cheng Y,
Heritier S, Morgenstern LB, Chalmers J; INTERACT Investigators. Intensive blood
pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised
pilot trial. Lancet Neurol. 2008 May;7(5):391-9.

Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J, Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. NEngl J Med. 2013 Jun 20;368(25):2355-65.
Hill MD, Muir KW. INTERACT-2: should blood pressure be aggressively lowered acutely after intracerebral hemorrhage? Stroke. 2013 Oct;44(10):2951-2.

June 2024