OBJECTIVES: Intracerebral hemorrhage carries high mortality and long-term disability. The optimal blood pressure (BP) management strategy-aggressive vs. conservative lowering-remains uncertain. This review compares both strategies.

DATA SOURCES: Articles from PubMed, Web of Science, Embase, and Cochrane were screened to August 2025.

STUDY SELECTION: Only randomized open-label blinded-endpoint trials were included.

DATA EXTRACTION: Patient characteristics, inclusion criteria, interventions, and outcomes were independently extracted by two authors; conflicts were resolved by a third.

DATA SYNTHESIS: Eight randomized controlled trials (12,669 patients; median age 63 yr; 60% male) met inclusion. No significant differences emerged between aggressive and conservative strategies for excellent functional outcome (risk ratio [RR], 1.07; 95% CI, 0.99-1.16; p = 0.94; I2 = 33%), good functional outcome (RR, 1.09; 95% CI, 0.99-1.20; p = 0.07; I2 = 51%), 90-day mortality (RR, 0.90; 95% CI, 0.77-1.05; p = 0.18; I2 = 0%), or hematoma growth (RR, 0.85; 95% CI, 0.66-1.10; p = 0.22; I2 = 48%). Aggressive BP lowering was associated with fewer adverse events (RR, 0.87; 95% CI, 0.76-0.99; p = 0.03; I2 = 59%). Sensitivity analyses showed significant benefits of the aggressive approach for good recovery (RR, 1.05; 95% CI, 1.01-1.10; p = 0.02; I2 = 0%), although not confirmed in the subgroup analyses (RR, 1.09; 95% CI, 0.97-1.23; p = 0.14; I2 = 61%). For adverse events, subgroup analyses consistently favored the aggressive strategy (RR, 0.81; 95% CI, 0.74-0.88; p < 0.01; I2 = 0%). No clear association with hematoma growth emerged, largely due to heterogeneity.

CONCLUSIONS: Aggressive and conservative BP lowering yielded similar outcomes for functional recovery, mortality, and hematoma growth. Aggressive BP lowering was linked to fewer adverse events, with some subgroup analyses suggesting modest functional benefits.

Emergency Medicine rater

This updated meta-analysis addresses a highly relevant emergency medicine question because blood pressure reduction is one of the earliest therapeutic decisions in acute intracerebral hemorrhage. The pooled data do not demonstrate a clear advantage for mortality, hematoma expansion, or 90-day functional outcomes, which is clinically important when interpreting current treatment targets. The reduction in adverse events is interesting, but should be interpreted cautiously because it was derived from only four studies, had substantial heterogeneity, and had heterogeneous event definitions. The study provides a useful contemporary synthesis rather than practice-changing evidence.