A 62-year-old man presents with sudden right-sided weakness. BP is 190/105 mmHg, GCS 15/15. Non-contrast CT shows a left basal ganglia intracerebral hemorrhage with no hydrocephalus. He has no history of recent antiplatelet use and no seizure activity. According to current guidelines, what blood pressure strategy is appropriate?

• A Administer sublingual nifedipine every 30 minutes until BP is controlled
• B Withhold antihypertensive treatment unless systolic BP exceeds 220 mmHg
• C Lower systolic BP rapidly to below 110 mmHg to prevent hematoma expansion
• D Lower systolic BP to below 140 mmHg within one hour, provided the presenting systolic BP was between 150 and 220 mmHg ✓

Explanation

For spontaneous intracerebral hemorrhage presenting with systolic BP between 150 and 220 mmHg, guideline-endorsed practice permits acute lowering to around 140 mmHg, supported by the INTERACT2 trial showing safety and possible functional benefit. Option B applies only when presenting systolic BP is above 220 mmHg. The ATACH-2 trial showed that aggressive targeting below 120 mmHg increases renal and other adverse events, ruling out option C. Sublingual nifedipine produces unpredictable precipitous falls and is never used in acute stroke.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.