We appreciated Dr. Munakomi’s response to our viewpoint1 on the data from Buletko et al.2 that suggested systolic blood pressure (BP) of 130 mm Hg as an ideal lower limit in BP reduction after spontaneous intracerebral hemorrhage (ICH). We agree with the comment on the remaining role for caution in aggressive BP reduction. However, a pressure autoregulatory shift to the right is disparate, complex, dynamic, not omnipresent,3 and should not prevail over compelling data that lower is better in BP reduction.4 Similarly, oxygen extraction fraction (OEF) as a predicate for therapeutic decision-making has not been successful.5 The focus of the index study was the lower limit of the targeted range.2 Clinicians may reconcile with a 130–160 mm Hg target, if worried about low goals. Others can use 120–140, but it may now be deemed unsafe to linger below 120, in view of the risk of ischemic deterioration.2 We agree that best management may lie ultimately in individualized goal-directed therapy, using autoregulation indices and neuroimaging biomarkers of ischemic risk (e.g., OEF). However, substantial observations have refuted a preponderant presence of perihematomal or regional ischemic penumbra in ICH.6 Serial OEF assessments in the hyperacute phase of ICH are seductive, but not readily applicable. Coupled with renal injury biomarkers, trending of multimodal neuromonitoring physiologic values may yield a U curve for stewardship of hyperacute BP reduction.

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