High systolic blood pressure variability is associated with impaired cerebral autoregulation and poor functional recovery after intracerebral hemorrhage.

Elevated systolic blood pressure variability (SBPV) has been linked to poor outcomes in intracerebral hemorrhage (ICH), but inconsistent evidence underscores the need for high-resolution studies. This study aimed to clarify the prognostic significance of SBPV in relation to secondary brain injury and functional outcomes in ICH. In 100 adults with supratentorial ICH, SBPV over the first 72 h—quantified using standard deviation (SD), coefficient of variation (CV), and average real variability (ARV)—along with cerebral autoregulation and hematoma dynamics, was analyzed. Higher SBPV was strongly associated with adverse radiological and clinical outcomes. Hematoma expansion occurred in 57% of patients in the high SBPV tertile compared with 12% in the low tertile (p < 0.001), while poor 90-day functional outcome occurred in 68% versus 15%, respectively (p < 0.001). After adjustment for established confounders, high SBPV independently predicted hematoma expansion (OR 4.1, 95% CI 1.9–8.9) and poor functional outcome (OR 3.8, 95% CI 1.8–7.7). Elevated SBPV was also associated with impaired cerebral autoregulation and increased perihematomal edema. Mediation analysis indicated that autoregulatory impairment and edema progression accounted for approximately 38% of the association between SBPV and poor outcome. Receiver operating characteristic analysis identified an SBPV SD value of approximately 17 mmHg associated with outcome discrimination (AUC 0.78), although findings overall supported a graded relationship between SBPV and risk rather than a strict threshold effect. These findings indicate that early increases in SBPV are associated with exacerbation of secondary brain injury and worse outcomes in conservatively managed ICH.