Ann Emerg Med. 2025 Dec 9:S0196-0644(25)01303-4. doi: 10.1016/j.annemergmed.2025.10.009. Online ahead of print.

STUDY OBJECTIVE: Blood pressure (BP) control is thought to be critical in acute intracerebral hemorrhage management. Here, we investigated whether reducing systolic BP ≤150 mm Hg within 2 hours of emergency department (ED) arrival is associated with improved outcomes and assessed the effect of excessive BP lowering («overshooting») on functional recovery.

METHODS: We conducted a retrospective cohort study of adult patients with spontaneous intracerebral hemorrhage (ICH) who presented to 2 academic medical centers between 2017 and 2023. We assessed the associations between blood pressure (BP) indicators, including BP control (≤150 mm Hg within 2 hours) and overshooting (<120 mm Hg), and the modified Rankin scale (mRS) score at discharge, dichotomized as a good (0 to 3) or poor (4 to 6) outcome, using logistic regression adjusted for ICH score, time from last seen well, and arrival BP.

RESULTS: Among 420 included patients, 323 (76.9%) had arrival BP>150 mm Hg. Of these, 62.8% received antihypertensive medications within 1 hour of ED arrival, and 71.2% achieved goal BP within 2 hours. Achieving goal BP within 2 hours of ED arrival was associated with worse outcomes (OR 2.32, 95% CI 1.17 to 4.57). Overshooting within 6 hours was associated with worse outcomes (OR 2.55, 95% CI 1.27 to 5.13). Antihypertensive medication type (bolus versus infusion) did not influence overshooting risk.

CONCLUSIONS: Although successful early BP reduction is common in ICH care, excessive lowering is also common and is associated with worse functional outcome. Caution is warranted to avoid overshooting during acute BP management.

PubMed:41369631 | DOI:10.1016/j.annemergmed.2025.10.009