Aggressive Blood Pressure Lowering for Intracerebral Hemorrhage Management: Chitra Venkatasubramanian, MBBS, MD, MSc, FNCS

WATCH TIME: 5 minutes

“So, blood pressure lowering is associated—or blood pressure that’s elevated is associated—with hematoma expansion, and hence the movement towards lowering the blood pressure, and then pushing the field forward and seeing how low can we actually go to give the most benefit for our patients by limiting the amount of hemorrhage that is expanding.”

Intensive blood pressure (BP) lowering in patients with spontaneous intracerebral hemorrhage (ICH) has long been considered a promising strategy to reduce hematoma expansion and improve outcomes. Although early concerns about reduced cerebral perfusion were addressed by imaging studies and initial trials, the larger INTERACT-2 trial (NCT00716079) showed only a modest, statistically borderline benefit of targeting a systolic BP of at most 140 mm Hg versus at most 180 mm Hg.¹ No significant differences were reported in mortality or major safety events, and the Rankin shift analysis favored the intensive treatment group only marginally.

At the 2025 American Academy of Neurology (AAN) Annual Meeting, held April 5-9, in San Diego, California, Chitra Venkatasubramanian, MBBS, MD, MSc, FNCS, clinical professor of stroke neurology and neurocritical care at Stanford University, participated in a debate on BP targets in ICH during the "Controversies in Neurology" plenary session. She argued in favor of lowering BP aggressively in the acute phase of ICH, contributing to an ongoing discussion about optimizing treatment strategies to improve patient outcomes.

After the session, Venkatasubramanian sat down with NeurologyLive^® to discuss the evolving approach to BP management following ICH. She highlighted the rationale for early and aggressive BP reduction, emphasizing its role in minimizing hematoma expansion. Drawing from major trials like the INTERACT-2 trial, she noted that although neither of them met their primary end points individually, pooled data support the safety and potential benefit of lowering systolic BP. The most benefit, she explained, was observed in younger patients without a history of chronic hypertension who presented in the first hour of symptom onset.

Click here for more coverage of AAN 2025.

REFERENCES
1. Hill MD, Muir KW. INTERACT-2: should blood pressure be aggressively lowered acutely after intracerebral hemorrhage?. Stroke. 2013;44(10):2951-2952. doi:10.1161/STROKEAHA.113.002790
2. Venkatasubramanian C. Yes: Blood Pressure Targets in ICH: Should We Go Low?. Presented at: 2025 AAN Annual Meeting; April 5-9; San Diego, CA. Controversies in Neurology Plenary Session.

Editor’s Note: Venkatasubramanian has disclosed that she has received personal compensation for serving as a Consultant for Ceribell and as an Expert Witness for McKeen and associates. She also has noted that she has stock in Ceribell. In addition, Venkatasubramanian has received research support from Bard Inc., Biogen, and NIH.