Blood Pressure in Acute Intracerebral Hemorrhage: Have We Been Looking in the Wrong Direction?

The role of hypertension in the pathogenesis of primary intracerebral hemorrhage (ICH) is indisputable. Large epidemiologic cohort studies have identified it as the most potent risk factor¹ and in other, observational studies elevated blood pressure (BP) in the acute phase of ICH was robustly associated with hematoma expansion, increased mortality and poor functional outcome.² In light of these findings and in the absence of any other medical or surgical intervention with proven benefit, BP has attracted substantial attention as a potential therapeutic target in the acute phase of ICH. Following encouraging results in early phase trials,³ 2 large, prospective phase III trials evaluated the effect of rapid, intensive systolic BP reduction in acute ICH: The INTERACT-2⁴ and ATACH-2⁵ trials both confirmed safety of the intervention but without benefits in mortality or functional outcome and these findings were confirmed in a recent meta-analysis pooling results of 5 randomized trials involving 4,360 patients.⁶ Naturally, the topic is hotly debated in the vascular neurology community, but the reasons for the trial failures and, most importantly, the optimal way to manage BP in acute ICH are far from resolved.

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