Table 3

Strategies for blood pressure management in acute ICH based on the most recent UK85 86 and US21 ICH management guidelines. Blood pressure management strategies in rows 1–3 are relevant to patients presenting within 6 hours of symptom onset

Blood pressure management questionsManagement strategy (for mild-to-moderate ICH)
What blood pressure warrants acute treatment? Reduce blood pressure in people with acute ICH who have a blood pressure of 150–220 mm Hg with symptom onset within the last 6 hours.
What blood pressure should I target? Aim for a systolic blood pressure of 130–140 mm Hg, sustained thereafter for at least a week.
How rapidly should I lower blood pressure? In most cases, aim to achieve the target blood pressure within 1 hour of starting treatment. Rapid blood pressure lowering should be avoided if elevated ICP is suspected, the GCS is <6, or neurosurgical evacuation is pending.
What agents should I use? Local protocols usually exist for guiding the choice of agent. Intravenous treatment (bolus or infusion) is generally warranted. Glyceryl trinitrate and labetalol are commonly used. Oral (or nasogastric) treatment should be started as soon as possible for maintenance treatment, and the intravenous therapy weaned and stopped within 2–3 days.
Should prehospital blood pressure treatment be advised? Prehospital treatment with glyceryl trinitrate appeared to worsen outcome in a subgroup analysis of the RIGHT-2 trial,87 so ultra-acute treatment may be harmful and should not be used.
  • ICH, intracerebral haemorrhage; ICP, intracranial pressure; GCS, Glasgow Coma Scale.