Should Aggressive Blood Pressure Management of Spontaneous Intracerebral Hemorrhage Be Guided with Invasive Blood Pressure Monitoring?

Early, intensive systolic blood pressure (SBP) lowering is recommended in acute spontaneous intracerebral hemorrhage (sICH), with growing emphasis on rapid target attainment and minimal blood pressure variability. However, outcome trials and guidelines have not addressed whether titration should be guided by invasive arterial blood pressure (IABP) or by intermittent noninvasive monitoring using a cuff. Evidence from emergency and intensive care unit (ICU) cohorts shows clinically meaningful disagreement between cuff and invasive measurements that widens at higher SBP and during motion-prone phases such as transport and agitation, precisely when active titration is needed. Variability in blood pressure measurements based on the technique will lead to differences in patient management that might impact outcome. In addition, data are scarce on how IABP monitoring should be operationalized to treat SBP more effectively, in a smooth and sustained fashion. This commentary delineates the key knowledge gaps and further research needed to define the role of invasive blood pressure monitoring in sICH.