Blood Pressure Control in Intraparenchymal Hemorrhage

Aim for goal systolic blood pressure (SBP) of 130-150 mmHg in most settings. The most recent guidelines from 2015 state:
 * Exceptions:
 * In patients with elevated intracranial pressure (ICP) from IPH, caution is advised before lowering BP acutely, as in the setting of elevated ICP, a drop in systemic BP could cause low cerebral perfusion pressure (CPP) and worsen brain injury.
 * In patients with very high SBP on presentation, it is reasonable to lower them more slowly, initially to <180 mmHg or so, and then lower them further. There is no clear evidence behind the approach, but it makes pathophysiological sense for a patient whose cerebral autoregulation may be shifted due to chronic hypertension.

However, these guidelines were published after the INTERACT-2 trial was published but prior to the publication of the ATACH-2 trial, which has changed our view on BP management. INTERACT-2 suggested that lowering of SBP in acute IPH to a goal of <140 mmHg was associated with a trend towards improvement in outcome with no adverse events. However, ATACH-2 showed no improvement in outcomes and a trend towards harm when SBP was lowered to <140 mmHg. In analyses of the actually achieved blood pressure in each study, it appears that harm tends to occur at SBP <120 or <130, and benefit may occur at BP <150. As such, it is reasonable to lower SBP to 130-150 mmHg in most settings of IPH.