by Simone Salemme
For November 2026 we have selected Ren X, Chen X, Hu X, et al. Effects of Blood Pressure Lowering by Hematoma Location in Acute Intracerebral Hemorrhage. Neurology. 2026;107(9):e218514. doi:10.1212/WNL.0000000000218514
Early intensive blood pressure (BP) lowering is an established component of acute intracerebral haemorrhage (ICH) management, but whether its benefits differ according to haematoma location remains uncertain. This question is particularly relevant because lobar, deep, and infratentorial haemorrhages differ in their underlying vascular pathology, clinical characteristics, and prognosis. In this individual participant data pooled analysis, Ren and colleagues investigated whether haematoma location modifies the effect of intensive BP lowering on functional outcomes after acute ICH.
The authors combined data from five international randomised trials (INTERACT1–4 and ATACH-II), including 11,288 patients with acute ICH (mean age 62.5 years; 35.9% women). Haemorrhages were classified as lobar (1,141 patients; 10.1%), deep (9,202; 81.5%), or infratentorial (945; 8.4%). The primary outcome was death or disability, defined as a modified Rankin Scale (mRS) score of 3–6, assessed at 90 days or six months for INTERACT3. Multivariable models accounted for trial-level differences and relevant clinical characteristics, including age, baseline BP, stroke severity, haematoma volume, and intraventricular haemorrhage.
The effect of intensive BP lowering on death or disability differed significantly by haematoma location (P for interaction=0.033). A clear benefit was observed in patients with deep ICH (adjusted odds ratio [aOR] 0.81, 95% CI 0.74–0.89), whereas no statistically significant benefit was detected in lobar (aOR 1.20, 95% CI 0.91–1.60) or infratentorial ICH (aOR 0.81, 95% CI 0.59–1.10). Similar patterns emerged for secondary functional outcomes, with intensive BP lowering associated with reduced death or severe disability (aOR 0.75, 95% CI 0.68–0.84) and disability alone (aOR 0.84, 95% CI 0.75–0.93) in deep ICH. Reductions in haematoma growth over 24 hours were also observed in this subgroup, although formal interaction tests did not establish differences between locations for this outcome.
Overall, these findings suggest that haematoma location may be an important modifier of treatment response in acute ICH, with the clearest evidence of benefit from intensive BP lowering observed in deep haemorrhages. The results support more anatomically informed approaches to acute ICH management and future trial design. However, the smaller lobar and infratentorial subgroups, differences in treatment protocols, and predominance of patients with mild-to-moderate ICH warrant caution. Importantly, the absence of statistically significant benefit in these subgroups does not establish treatment ineffectiveness. Further studies are needed before haematoma location can independently guide decisions about BP-lowering intensity.
