Blood Pressure Management After Intracerebral and Subarachnoid Hemorrhage

The Knowns and Known Unknowns

Jatinder S. Minhas, MD; Tom J. Moullaali, MD, PhD; Gabriel J.E. Rinkel, MD, PhD; Craig S. Anderson, MD, PhD


Stroke. 2022;53(4):1065-1073. 

In This Article


This focused update has outlined the current evidence, knowledge gaps, and emerging concepts on systemic hemodynamics, cerebral autoregulation, and perfusion. We summarize several clinical research priorities in ICH and SAH (Table). Specifically, the emergence of PaCO2 change as an important modifier of response to intervention (BP lowering) and prognostic marker may allow ultra-acute data on systemic and cerebral hemodynamics in ICH to be obtained, particularly pre- and post-BP agent delivery. Given the overlap in clinical questions, pathophysiology and complications across these 2 subtypes of hemorrhagic stroke, we call for greater international and cross-disciplinary capacity-building collaborations between ICH and SAH researchers. There is potential value in further IPD meta-analyses of RCT data to understand differences in ICH associated with SAH, and vice versa, but also in using novel platform registries with nested RCTs that can address multiple research questions within a common infrastructure. Although less ideal for assessing effectiveness, the use of propensity-score matching and artificial intelligence methodologies of large prospective cohort datasets can allow an assessment of all aspects of patient management. Lastly, by considering the pathophysiological overlap between ICH and SAH, we may better understand the potential benefits of pharmacological agents in both contexts rather than isolation (eg, is there a role for nimodipine in ICH?).