Intensive Blood Pressure Lowering for Intracerebral Hemorrhage: A Systematic Review and Updated Meta-analysis of Randomized Controlled Trials

BackgroundIntracerebral hemorrhage (ICH) is often associated with elevated blood pressure (BP), increasing the risk of persistent and recurrent hemorrhage, disability, and death. Previous studies have reported conflicting results regarding BP management, particularly concerning treatment timing and optimal targets. The aim of this review was to perform a systematic review and meta-analysis comparing intensive BP lowering with standard management in patients with ICH.MethodsPubMed, Embase, and Cochrane Library databases were searched for randomized controlled trials (RCTs) comparing intensive BP lowering (target < 140 mm Hg) with standard management in patients with ICH. Outcomes included good functional outcome (modified Rankin scale [mRS] score 0-2), poor functional outcome (mRS score 3-6), all-cause mortality, and substantial hematoma enlargement. Subgroup analyses assessed (1) BP target thresholds, (2) randomization window (< 6 h vs. >= 6 h from symptom onset), and (3) BP target type (systolic blood pressure based vs. mean arterial pressure based). All analyses were conducted based on risk ratios (RR) and 95% confidence intervals (CIs) using a random-effects model.ResultsEleven RCTs (13,625 patients; 6,755 in the intensive group) were included. Intensive BP lowering was associated with a significant reduction in poor functional outcome (mRS score 3-6; RR 0.93, 95% CI 0.90-0.96; p < 0.01) and an increase in good functional outcome (mRS score 0-2; RR 1.09, 95% CI 1.01-1.18; p = 0.03). All-cause mortality (RR 0.86, 95% CI 0.79-0.94; p < 0.01) and substantial hematoma enlargement (RR 0.83, 95% CI 0.73-0.95; p < 0.01) were also significantly lower in the intensive group. The subgroup analyses revealed no significant interactions.ConclusionsThese findings suggest that intensive BP lowering in ICH might be associated with improved functional outcomes and lower risks of death, disability, and hematoma enlargement, supporting its potential role in acute management.