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The Best in FOAM Education

  • Wei Li, MD

Blood Pressure Management in Intracranial Hemorrhage

A 64 year old with past medical history of hyperlipidemia (HLD), acid reflux, and hypertension (HTN) presents to the ED with a headache. He states the symptoms started when he was working on his pool this afternoon. The headache began gradually 3 hours ago and now is an 8/10 in severity. It is in the right temporal region. The patient denies any similar headaches in the past. He took Tylenol prior to arrival with minimal relief of pain. He denies any current visual changes, weakness, or numbness in his arms or legs. He states he felt nauseous just prior to arrival but the sensation has passed. He denies chest pain.

Medical history: HTN, HLD, GERD

Social: former pack per day smoker for 15 years, quit 10 years ago, wine once a week, denies IV drug use

Surgical history: Cholecystectomy 10 years ago

Meds: Amlodipine, atorvastatin, omeprazole


  • VS: HR 63, BP 185/98, O2 100%, RR 16, T 36.8

  • General: Mild distress due to headache but speaking in full sentences.

  • HEENT: Unremarkable, head non-tender, atraumatic exam, pupils equal and reactive to light, EOMI, no visual field deficits

  • Pulmonary: Clear to auscultation, no wheezes or crackles

  • CV: regular rate and rhythm, no murmurs or gallops

  • Abdomen: Soft, nontender, no rebound or guarding

  • Neuro: Alert and oriented x 3, cranial nerves intact, 5/5 strength in all extremities, sensory intact, finger to nose normal

Given the history and vitals you are concerned about potential intracranial pathology and called CT to get the patient to the scanner STAT!

The CT-head shows left lobar intracranial hemorrhage with a hematoma size of 25 ml. 

The blood pressure is now 190/100! However, the patient is still awake and speaking in full sentences.

Lots of medical management involved with ICH. As always start with ABCs. Get fingerstick, CT scan, reverse Anticoagulants 

Focus of this MR will be on BP management in ICH

Why is BP management important for ICH?

One reason is to prevent hematoma expansion. Worsening hematoma expansion can lead to worse clinical outcomes

Does dropping BP too much lead to ischemia to surrounding tissue?

There are some concerns that acutely lowering BP in someone with an intracranial hemorrhage can lead to decreased perfusion to the brain tissue around the hematoma.

What the AHA Guidelines, ATACH II trial, and INTERACT II trial Say About BP Goals

American Heart Association/American Stroke Association guidelines recommends acutely lowering SBP to 140 in those presenting with ICH


  • Compared intensive SBP (<140mmHg) vs guideline-recommended (<180mmHg) in patients with ICH. Used antihypertensives of physicians’ choice to lower SBP within one hour

  • Primary outcome was death or major disability (over 3 on modified Rankin scale) at 90 days

  • No statistical difference in 90 days in death or severe disability but the intensive group did have statistically lower modified Rankin scores 


  • Patients with ICP were randomized to two groups, one group with SBP goal of 110-139 the other 140-179. 

  • Only used Nicardipine

  • Primary end point was if there was a mortality benefit or improvement in disability in the two groups

  • There was no difference between the two groups

Which agent should one use for BP control?

  • First, control pain if patient is awake!

  • Second, make sure the patient is adequately sedated if they are intubated

  • Nicardipine is the agent of choice for most centers in the US

    • Fast onset ~15 mins and relatively titratable 6

    • Dose: 5mg/hr to start, increase 2.5mg every 15mins – once you reach BP goal, titrate the drip down 3mg (because of the reason above)

    • Pure arterial vasodilator with cerebral vasodilation 


Wei Li, MD is a current second year resident at Stony Brook Emergency Medicine. References

  • Sakamoto Y, Koga M, Yamagami H, et al. Systolic blood pressure after intravenous antihypertensive treatment and clinical outcomes in hyperacute intracerebral hemorrhage: the stroke acute management with urgent risk-factor assessment and improvement-intracerebral hemorrhage study. Stroke. 2013;44(7):1846-1851. doi:10.1161/STROKEAHA.113.001212 Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365. doi:10.1056/NEJMoa1214609

  • Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032-2060. doi:10.1161/STR.0000000000000069

  • Anderson CS, Huang Y, Arima H, et al. Effects of early intensive blood pressure-lowering treatment on the growth of hematoma and perihematomal edema in acute intracerebral hemorrhage: the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT). Stroke 2010; 41:307.

  • Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016;375(11):1033-1043. doi:10.1056/NEJMoa1603460


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