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ICH and BP management

Spontaneous (non-traumatic) Subarachnoid Hemorrhage (SAH):

  • Goal SBP < 140-160 mmHg
  • Medication options:
    • Labetalol IV 10mg boluses
    • Nicardipine infusion
    • Celvidipine infusion
  • Avoid vasodilating agents like nitroprusside or nitroglycerin

Spontaneous (non-traumatic) Intracerebral Hemorrhage:

  • Goal SBP < 140 mmHg
  • AHA / ASA guidelines (2015) give the following recommendation:

    “For ICH patients presenting with SBP between 150 and 220 mm Hg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe (Class I; Level of Evidence A) and can be effective for improving functional outcome (Class IIa; Level of Evidence B). (Revised from the previous guideline)”

  • INTERACT 2 (2015) trial found no difference in risk of death or severe disability with aggressive BP reduction, SBP <180 vs <140 within first hour..
  • ATACH-2 trial (2016) also found no benefit to aggressive BP lowering < 140 mmHg vs <180 mmHg
  • Medication options:
    • Labetalol IV 10mg boluses
    • Nicardipine infusion
    • Celvidipine infusion

Traumatic Subdural Hematoma (SDH), Subarachnoid Hemorrhage (SAH), Epidural Hematoma (EDH), Intra-parnechymal Hemorrhage:

  • Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) – intracranial pressure (ICP)
  • Goal CPP 50-60 mmHg
  • If no ICP monitor, Brain Trauma Foundation guidelines include level III evidence:
    • SBP >100 mmHg age 50-69
    • SBP >110 mmHg age 15-49 or >69
  • BP above is a minimum, not a target BP.
  • Keeping SBP < 200 mmHg is generally felt to be beneficial
  • Hypotension (<90 mmHg) is known to increase morbidity and mortality
  • CPP goal is most accurate.
  • If BP is high, consider treating for pain first.

Traumatic brain injury without bleeding (low GCS, diffuse axonal injury):

  • Treat BP is >200 mmHg
  • Consider treating for pain
  • Ensure adequate sedation if intubated
  1. Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2012;43(6):1711-37. PubMed , Full Text
  2. Hemphill JC, 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):2032-60. PubMed , Full Text
  3. Anderson CS, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. The New England Journal of Medicine. 2015. 368(25):2355-2365 PubMed , Full Text
  4. Qureshi, AI et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl Med. 2016 Sep 15;375(11):1033-43. PubMed , Full Text
  5. Brain Trauma Foundation 4th Edition Guidelines, 2016 Full Text
  6. Anand Swaminathan, MD FAAEM and Evie Marcolini, MD; Blood Pressure Management in Neurocritical Care ; EMRAP Oct 2018 Episode
  7. Mel Herbert, MD MBBS FAAEM and Rob Orman, MD; ATACH-2 Trial; EMRAP Short June 2016 Episode

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