Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)


Nursing Science

Research Advisor

Anne Alexandrov, PhD


Carolyn Graff, PhD; Carrie Harvey, PhD; Edward Jauch, MD; Mani Paliwal, MS


acute care;acute non-traumatic intracerebral hemorrhage;Bland-Altman;blood pressure;limits of agreement


Purpose. Blood pressure (BP) management is difficult and complex in the treatment of acute non-traumatic intracerebral hemorrhage (ICH). Despite mean arterial pressure (MAP) being the most reliable measure of noninvasive automatic oscillometric (NIBP) in clinical practice, clinicians instead rely on systolic and diastolic blood pressure (SBP and DBP) values to guide clinical practice. Given the widespread use of NIBPs for obtaining BP values in the acute care setting, we determine the agreement between SBP, DBP, and MAP measured by NIBP, manual cuff, and Arterial lines (A-lines) in patients with ICH. Study Aims. To understand the agreement between SBP, DBP, and MAP measured by manual sphygmomanometry performed by trained healthcare providers with 1) NIBP, and, if applicable, 2) A-line measurements in patients with acute non-traumatic ICH. Secondary aims were to explore the relationship between BP values, hematoma expansion and outcomes in death and disability in patients with ICH. Methods. Using established guidelines for the assessment of agreement between devices, a prospective observational study of agreement between BP methods (NIBP, manual, and A-line) was conducted in patients with ICH within the first 24 hours of admission at two comprehensive stroke centers (CSC). Investigators used a dual auscultatory stethoscope to validate each manual BP variable. Calculation of MAP was done for manual BPs using the standard formula. A-line measures were zeroed, leveled to the phlebostatic axis, and checked for proper waveforms prior to use. Data were analyzed using the Bland-Altman (BA) analyses. Results. Our study found no agreement in SBP, DBP, and MAP for 650 paired manual and NIBP measurements. NIBP measures were consistently lower than manual, with DBP (p = < .001) measuring in the least agreement between methods, followed by SBP (p = .005), and the closest was MAP (p = < .001) using BA analysis. The differences were also analyzed for the percentage of measurements that fell within a difference of 5, 10, 15, and 20 mmHg for SBP, DBP, and MAP separately. For SBP, 58% of the 650 sets of measures fell within 10 mmHg. For DBP, 63% fell within 10 mmHg. For MAP, 76% fell within 10 mmHg. For the 25 paired manual, NIBP, and A-line measurements, there was no agreement in SBP, DBP, and MAP, with MAP being the closest value in agreement between the methods, followed by DBP and then SBP. The A-line measures were consistently higher than Aline with manual measures. For our secondary aims, we found no relationship between the NIBP vs manual values with outcomes in patients with ICH. Conclusion. Theoretically, lowering BP decreases the risk of hematoma, making blood pressure control a top priority in acute ICH care. Before we can set forth targeted BP goals for ICH, research must be guided by valid BP measurements to further our understanding of the utility of aggressive BP lowering, as well as its safety in the care of patients with ICH. It is imperative that proper BP measurements are performed and appropriate treatment goals are established, making examination of the agreement between devices and continued exploration of the use of MAP paramount in the management of acute intracerebral hemorrhage.

Declaration of Authorship

Declaration of Authorship is included in the supplemental files.




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