The Key Role of Early and Balanced Blood Pressure Control in ICH Management: Kara R. Melmed, MD

WATCH TIME: 4 minutes

"We want to make sure we're getting enough blood to the brain, we're perfusing the brain, but we're not causing any adverse events that might occur with lowering blood pressure."

A large international trial, known as INTERACT3 (NCT03209258), investigated whether a structured, hospital-implemented care bundle could improve outcomes for patients with acute spontaneous intracerebral hemorrhage (ICH). The bundle included early intensive blood pressure control, as well as management of hyperglycemia, fever, and anticoagulation. Conducted across 121 hospitals in 10 countries, the study used a stepped wedge cluster randomized design to compare usual care with the care bundle in over 7000 patients presenting in 6 hours of symptom onset.¹

In the trial, results showed that patients who received the care bundle had significantly better functional outcomes at 6 months, as measured by the modified Rankin Scale, and experienced fewer serious adverse events compared with those receiving usual care. Researchers noted that the benefit was consistent across sensitivity analyses, supporting the effectiveness of the bundled approach. These findings suggested that hospitals should adopt this early, goal-directed strategy as part of standard care for managing acute ICH.

At the 2025 American Academy of Neurology (AAN) Annual Meeting, held April 5-9, in San Diego, California, Kara R. Melmed, MD, clinical associate professor of neurology and neurosurgery at NYU Langone Health, participated in a debate on target blood pressure for ICH.² After the session, Melmed sat down with NeurologyLive^® to discuss current strategies and evidence guiding the acute management of patients with ICH. Citing trials such as INTERACT3, Melmed noted that overly aggressive blood pressure lowering may lead to adverse events like acute kidney injury and cerebral hypoperfusion. She also emphasized that time to treatment is critical, and that bundled care approaches are showing promising benefits in improving outcomes.

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REFERENCES
1. Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial [published correction appears in Lancet. 2023 Jul 15;402(10397):184. doi: 10.1016/S0140-6736(23)01420-4.]. Lancet. 2023;402(10395):27-40. doi:10.1016/S0140-6736(23)00806-1
2. Melmed KR. No: Blood Pressure Targets in ICH: Should We Go Low?. Presented at: 2025 AAN Annual Meeting; April 5-9; San Diego, CA. Controversies in Neurology Plenary Session.