How should I manage blood pressure in a patient with an acute intracerebral haemorrhage?

In managing blood pressure in a patient presenting with an acute intracerebral haemorrhage (ICH), rapid blood pressure lowering should be considered if the patient presents within 6 hours of symptom onset and has a systolic blood pressure between 150 and 220 mmHg, provided there are no exclusions such as an underlying structural cause, a Glasgow Coma Scale score below 6, planned early neurosurgery, or a massive haematoma with poor prognosis ¹.

The target when lowering blood pressure rapidly is to achieve a systolic blood pressure of 140 mmHg or lower, ensuring that the reduction does not exceed 60 mmHg within the first hour of treatment ¹.

For patients presenting beyond 6 hours or with systolic blood pressure greater than 220 mmHg, rapid blood pressure lowering should be considered on a case-by-case basis, weighing the risks and benefits ¹.

In younger patients aged 16 or 17, specialist paediatric advice should be sought before initiating blood pressure lowering ¹.

These recommendations align with evidence that careful and controlled blood pressure reduction can limit haematoma expansion and improve outcomes, while avoiding excessive drops that may compromise cerebral perfusion (Flower and Smith, 2011; Grise and Adeoye, 2012).

Recent literature also highlights the importance of managing blood pressure variability during acute stroke, as fluctuations may influence outcomes, suggesting that stable and controlled blood pressure management is crucial (Zompola et al., 2024).