(New recommendation) BP and Outcome in ICH Elevated BP is very common in acute ICH121,122 because of a variety of factors, including stress, pain, increased ICP, and premorbid acute or persistent elevations in BP. High SBP is associated with greater hematoma expansion, neurological dete- rioration, and death and dependency after ICH.122 124 Compared with ischemic stroke, in which consistent U- or J-shaped asso- ciations between SBP nadir of 140 and 150 mmHg and poor outcome have been shown,125 only 1 study of ICH has shown a poor outcome at low SBP levels (<140 mmHg).126 Safety of Early Intensive BP-Lowering Treatment Observational studies with advanced neuroimaging have shown no significant ischemic penumbra in ICH,127 with the perihematomal rim of low attenuation seen on CT being related to extravasated plasma.128 A randomized clinical trial using CT perfusion in primarily small and medium ICH found no clinically significant reduction in cerebral blood flow within the perihematomal region related to early intensive BP lowering to an SBP target of <140 mmHg within several hours In a clinical cohort of 211 patients who received a standard protocol of nicardipine-based BP lowering to reach an SBP target of <160 mmHg at a mean of 30 minutes (range, 15 45 minutes) within 3 hours of the onset of ICH, the best outcomes were seen in the group with the lowest achieved Both the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) trial, a 4-tier dose- escalation study of intravenous nicardipine-based BP low- ering in 80 patients within 3 hours of ICH,130 and the pilot phase Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage (INTERACT1) trial in 404 mainly Chinese patients within 6 hours of ICH131 found rapid reduction of SBP to <140 mmHg to be safe.132,133 Most recently, the main phase INTERACT2 trial has shown no increase in death or serious adverse events from early intensive BP lowering in eligible patients with elevated SBP.134 Several observational studies have demonstrated that small ischemic lesions identified on diffusion-weighted MRI are common after ICH; however, the impact on outcome and relationship with BP lowering vary Efficacy of Early Intensive BP-Lowering Treatment The largest randomized clinical trial evaluating the efficacy of intensive BP lowering is INTERACT2, a phase 3 trial undertaken in 2839 patients with SBP between 150 and 220 mmHg within 6 hours of ICH.134 Among 2794 participants for whom the primary outcome could be determined, 719 of 1382 participants (52.0%) receiving intensive treatment (to an SBP target of <140 mmHg within 1 hour of randomiza- tion and for a duration of 7 days, following protocols that included locally available intravenous agents) compared with 785 of 1412 participants (55.6%) receiving standard treat- ment (SBP <180 mmHg) had a primary outcome of death or major disability (modified Rankin scale score 3; OR, 0.87; 95% CI, 0.75 1.01; P=0.06). 