Among factors associated with functional outcomes after intracerebral hemorrhage (ICH), hematoma growth consistently emerges as the most relevant potentially modifiable risk factor for poor outcomes.1,2 Short-term treatment strategies to reduce hematoma growth have pursued 2 pathways: improving hemostasis and reducing extravasation by means of blood pressure reduction. Basic principles of fluid mechanics suggest that a larger pressure gradient across the arteriole wall will increase the likelihood of rerupturing and, in the case of incomplete thrombosis of the ruptured vessel wall, will increase the rate of extravasation. In patients with aneurysmal subarachnoid hemorrhage, in whom vessel rerupture is a more readily ascertained event, studies indicate that higher systolic blood pressure (SBP) is a risk factor for rebleeding. In ICH, the presence of perihematomal contrast extravasation (called the spot sign) indicates ongoing extravasation and is associated with higher blood pressure. Evidence linking blood pressure, perihematomal edema, and outcomes has been reported but is less well established.3 It is on this foundation that rapid blood pressure reduction has been pursued as a protective strategy.
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Maas MB. Intensive Blood Pressure Reduction in Patients With Intracerebral Hemorrhage and Extreme Initial Hypertension: Primum Non Nocere. JAMA Neurol. 2020;77(11):1351–1352. doi:10.1001/jamaneurol.2020.3081
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