Early Intensive Blood Pressure Reduction After Intracerebral Hemorrhage Is Associated With Worse Functional Outcome: The Risk of Overshooting Blood Pressure Goals - 10/12/25

Doi : 10.1016/j.annemergmed.2025.10.009

Aria C. Shi, MD ^a,^b,^c,^⁎ , Thomas Taylor, BS ^b, Chuan-Chin Huang, ScD ^c,^d, Aneesh B. Singhal, MD ^c,^e, Joshua N. Goldstein, MD, PhD ^b,^c, Matthew B. Bevers, MD, PhD ^c,^f, Peter C. Hou, MD ^a,^c,^g
^a Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA
^b Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
^c Harvard Medical School, Boston, MA
^d Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
^e Department of Neurology, Massachusetts General Hospital, Boston, MA
^f Division of Neurocritical Care, Department of Neurology, Brigham and Women’s Hospital, Boston, MA
^g Division of Emergency Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Wednesday 10 December 2025

Abstract

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.

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Keywords : Blood pressure, Hemorrhagic stroke, Intracerebral hemorrhage, Intraparenchymal hemorrhage

Plan

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor : Robert D. Welch, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at editors .
	Author contributions: ACS, JNG, and MBB conceived the idea for the study. ACS, MBB, and PCH designed the study. ABS, JNG, and MBB provided access to the data in this study. ACS and TT collected and managed the data, with guidance from MBB. PCH supervised the conduct of the study. ACS and C-CH performed the data analysis. ACS drafted the manuscript, and all authors contributed to its revisions. MBB and PCH contributed equally to this work as senior authors. ACS takes responsibility for the paper as a whole.
	Data sharing statement: The entire deidentified data set, data dictionary and analytic code for this investigation are available on request, from the date of article publication by contacting Aria C Shi, MD at ariashi@alum.mit.edu .
	Authorship : All authors attest to meeting the four ICMJE.org authorship criteria:(1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Fundingandsupport: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/ ). This work was supported by the Brigham & Women’s Richard C. Wuerz, MD, Award for Emergency Medicine Research. MBB received support from NINDS related to intracerebral hemorrhage (K23NS112474). We do not have conflicts of interest to disclose regarding the content of this article. JNG reports consulting fees from Astrazeneca, CSL Behring, Pfizer, Octapharma, Takeda, and Cayuga.
	Presentation information: Abstracts of this work were presented at the Society for Academic Emergency Medicine (SAEM) New England Regional Meeting on April 2, 2025, in Worcester, MA, USA and the SAEM Annual Meeting on May 14, 2025, in Philadelphia, PA, USA.