Abstract

Acute blood pressure (BP) management after intracerebral hemorrhage (ICH) has traditionally emphasized attainment of a systolic blood pressure (SBP) target. The presented work supports viewing BP as a dynamic physiologic signal in which fluctuation, instability, overshoot, and variability may be associated with outcome. Because SBP remains the principal treatment parameter in acute stroke care, a proposed next step is not simply BP
reduction, but stabilization using higher-order SBP features. Post hoc analyses from ATACH-2 and pooled analyses of INTERACT2 and ATACH2 suggest that early SBP fluctuation is associated with neurological deterioration, hematoma expansion, death, and functional disability, whereas achieving “SBP reduction with stability”—maintaining SBP between 130 and 150 mm Hg within 1 hour on consecutive recordings—was associated with better
outcomes. These observations support SBP variability as a therapeutic target. An AI-focused framework is therefore proposed for acute ICH care: real-time acquisition of second- and third-order SBP variables, continuous display of these variables on ICU monitors, and integration of algorithm-guided dose adjustment into automated infusion
pumps. In this model, incoming physiologic data are matched with treatment algorithms and historical dose-response information to support dynamic infusion decisions over time. The ongoing CLUTCH trial provides a clinical context for this strategy by evaluating whether intravenous clevidipine improves achievement of SBP target with stability within 60 minutes.