Intracranial hemorrhage

There is no consensus regarding the degree to which elevated blood pressure should be reduced in patients with intracranial hemorrhage. In the setting of subarachnoid hemorrhage, there are concerns regarding vasospasm; it is feared that reductions in blood pressure can further impair perfusion to an already ischemic zone. However, the complication rate in patients with subarachnoid hemorrhage is increased when blood pressure is particularly high (e.g. systolic blood pressure above 160-180 mmHg) (lie.tlen.et.a/ 1996). In addition, trials utilizing calcium-channel blockers (specifically nimodipine) have shown a small benefit, although it is unclear whether it is due to their effect on the blood pressure ( CaJhoun.and.OparjJ 1990). The recommendation is to decrease blood pressure gradually by 20 to 25

per cent, or to an mean arterial pressure of 110 to 120 mmHg, over a period of 6 to 12 h. Initial therapeutic agents include calcium-channel blockers (e.g. nimodipine or nifedipine), starting with low doses, or sodium nitroprusside in patients unable to take oral medication. If blood pressure reduction appears to worsen the patient's overall status, the antihypertensive agents should be discontinued immediately and blood pressure allowed to return to moderately elevated levels. Experiences with hypertensive intraparenchymal cerebral hemorrhage are limited and there no controlled trials. Currently, the recommendations are the same as those for subarachnoid hemorrhage, with similar goals for target blood pressure and time frame (C§!hoy0...aDd O.p§rL! 1990).

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