ESO Webinar report: Blood pressure management in patients with ICH

On 28 October the ESO educational webinar tackled the topic of blood pressure (BP) management in patients with ICH, moderated by Anna Bersano and Thorsten Steiner. Two expert speakers—Andrea Morotti and Trine Apostolaki‑Hansson—took us through the evolving landscape of BP control in acute treatment and secondary prevention of ICH.

Dr. Morotti opened by asking whether intensive BP control truly improves clinical outcomes in spontaneous ICH. His talk presented the concept of hematoma expansion as a treatment target, with benefits expected to translate into clinical outcome. Dr. Morotti reviewed clinical trials testing this concept in acute ICH, many supporting the impact on hematoma growth but showing less consistent results on functional outcome. However, a recent pooled analysis of the INTERACT trials demonstrated a favourable shift in 3-month functional outcome in the intensive BP arm.¹

Dr. Morotti remarked that despite the benefits of BP lowering, intensive reduction may be harmful for patients with very large ICH volumes, and baseline systolic BP > 220 mmHg. By contrast, the greatest likely benefit appears in early presenters with ICH volume < 30 mL. He also underscored that BP variability should be avoided and called for more data on lobar and very severe ICH, extreme BP elevations, and BP management in patients undergoing surgery. In her talk, Dr. Apostolaki-Hansson addressed both the acute phase and secondary prevention of ICH. She summarised the evidence in acute BP management by referencing the ESO and EANS guideline on spontaneous ICH that found a trend toward less hematoma expansion, but no significant difference in 3–6-month functional outcome or mortality between intensive versus standard care.² According to expert consensus, a target SBP <140 mmHg within 6 hours is recommended in minor-to-moderate ICH, but excessive drops and too low BP should be avoided. Turning to prevention, Dr. Apostolaki-Hansson highlighted hypertension as a major modifiable risk factor for ICH. In secondary prevention, patients with poor BP control 3 months post-ICH have higher recurrence, major adverse cardiovascular events, and mortality. The ESO and EANS guideline therefore recommends BP control after ICH with the target of <130/80 mmHg.² She also acknowledged current challenges of long-term BP management, including early start after ICH, commitment to treatment targets, and adherence. One promising approach was recently introduced by the TRIDENT trial on an antihypertensive triple‐pill to prevent recurrent stroke after ICH, presented in the World Stroke Congress in October 2025.

During a lively discussion, both experts agreed that despite remaining uncertainties, “time is brain” also applies in BP reduction for ICH and that BP management is preferably integrated as part of a care bundle yielding synergistic benefit.

1. Wang X, Ren X, Li Q, et al. Effects of blood pressure lowering in relation to time in acute intracerebral haemorrhage: a pooled analysis of the four INTERACT trials. Lancet Neurol 2025 July; 24(7): 571–9.
2. Steiner T, Purrucker JC, Aguiar de Sousa D, et al. European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) guideline on stroke due to spontaneous intracerebral haemorrhage. Eur Stroke J 2025 May 22; 23969873251340815.

Learn more about our Webinars: https://eso-stroke.org/educational-webinars/