Association between cerebral autoregulation and optimal cerebral perfusion pressure after hypertensive intracerebral hemorrhage under neuromultimodal monitoring

Objective Standardized blood pressure thresholds cannot address individualized cerebral perfusion needs in hypertensive intracerebral hemorrhage (HICH). The role of optimal cerebral perfusion pressure (CPPopt) and its association with multimodal cerebral indices in HICH remain poorly defined. This study investigated whether a CPPopt-guided strategy improves cerebral autoregulation and explores its association with outcomes. Methods This single-center retrospective study included 97 HICH patients who underwent multimodal neuromonitoring for pressure reactivity index (PRx), index of cerebrospinal compensatory reserve capacity (RAP), mean flow index (Mx), and cerebral oximetry index (COx). Patients were grouped by ΔCPPopt (actual CPP – CPPopt). Outcome was assessed by 3-month modified Rankin Scale (mRS). Relationships between monitoring parameters and CPPopt were analyzed, and the potential impact of CPPopt on prognosis was explored. Results In the ΔCPPopt −5 to 5 mmHg group, PRx (0.03 ± 0.06), Mx (0.07 ± 0.07) and COx (0.02 ± 0.05) were near 0, with RAP (0.17 ± 0.05) significantly lower than other groups ( P < 0.001). ICP decreased linearly with increasing CPP. PRx, RAP and Mx reached their lowest values near CPPopt, while COx remained stable at ΔCPPopt of 0–20 mmHg. Conclusions Both cerebral autoregulatory function and intracranial compensatory reserve are closely associated with CPPopt in HICH. Maintaining CPP near CPPopt simultaneously optimizes cerebral physiological status; hypoperfusion and elevated ICP cause more severe impairment than hyperperfusion. This study extends prior evidence predominantly derived from traumatic brain injury cohorts and provides multimodal physiological evidence to support individualized perfusion management in HICH. Large-scale prospective studies are warranted to validate the clinical utility of CPPopt-guided strategies in HICH.