Prehospital intensive blood pressure management in intracerebral hemorrhage: current evidence, controversies, and future directions

Spontaneous intracerebral hemorrhage (ICH) is a severe neurological emergency. Early hematoma expansion(HE), a key modifiable outcome predictor, occurs in approximately 38% of cases. This review synthesizes evidence on prehospital intensive blood pressure (BP) management. Reducing systolic BP to <140 mmHg within two hours of onset limits hematoma growth and may improve functional outcomes. However, the INTERACT-4 trial revealed risks in misdiagnosed ischemic stroke, underscoring the need for accurate prehospital subtyping. RIGHT-2 and MR ASAP trials showed no benefit and potential harm with glyceryl trinitrate (GTN). Mobile stroke units enable faster treatment but face cost and scalability barriers. Controversies persist over optimal BP targets, timing, and patient selection. Future directions include developing "Code ICH" pathways, establishing individualized BP targets, and prospectively validating precision medicine approaches.