Study Results Support Rapid Blood Pressure Reduction After Spontaneous Intracerebral Hemorrhage

Findings from a secondary analysis of data from the phase 3 ATACH-II clinical trial (NCT01176565) suggest that intensive systolic blood pressure (BP) reduction to below 140 mmHg within 90 minutes of randomization is associated with decreased risk of hematoma expansion (HE) for people with spontaneous intracerebral hemorrhage (ICH). In this study, randomization took place within 4.5 hours after spontaneous ICH symptom onset. The results of this secondary analysis, which were presented at the American Academy of Neurology (AAN) 2025 Annual Meeting, demonstrate the value of rapid BP management in the management of acute ICH.

The results derive from an exploratory analysis of data from ATACH-II, which included 970 participants with supratentorial hemorrhages and complete BP data. In ATACH-II, participants were randomized to receive standard intervention, reducing systolic BP to <180 mmHg or to receive an intensive BP reduction to <140 mmgHg. Randomization occurred ≤4.5 hours after symptom onset.

In the secondary analysis, researchers evaluated the occurrence of HE, defined as an increase in hematoma volume >6 mL on imaging performed 24 hours after randomization. Kaplan-Meier curves were utilized to compare the timing of BP control between patients who experienced HE and those who did not. Melded β tests determined the time point at which BP trajectories significantly diverged, and logistic regression models assessed the association between achieving target BP by specific time points and the likelihood of HE.

Key findings:

• The median time to achieve systolic BP <140 mmHg was 90 minutes (interquartile range [IQR], 143 minutes).
• BP trajectories between patients with and without HE diverged significantly at 90 minutes postrandomization (Odds Ratio [OR], 1.46; 95% CI, 1.03 to 2.06).
• Achieving BP control by 90 minutes was linked to decreased odds of HE (unadjusted OR, 0.7; 95% CI, 0.6 to 0.9; adjusted OR, 0.6; 95% CI, 0.4 to 0.9).

These results suggest that targeting systolic BP reduction to below 140 mmHg early after presentation may be a critical therapeutic goal to minimize HE in acute ICH patients.