Systemic Adverse Effects of Intensive Blood Pressure Treatment After Craniotomy for Tumor Resection

BACKGROUND AND OBJECTIVES: Postcraniotomy hypertension is commonly treated with intravenous (IV) antihypertensives to reduce hemorrhage risk. Intensive systolic blood pressure (SBP) control has been associated with adverse effects in hospitalized patients, but its impact after craniotomy is unclear. This study evaluated whether IV nicardipine use to achieve an SBP target <140 mm Hg is associated with hypoperfusion and other adverse outcomes after craniotomy. METHODS: We retrospectively reviewed 1997 adult craniotomy cases (2019-2024) at a tertiary academic center, stratified by IV nicardipine use. The comparison group included patients who received intermittent IV antihypertensives or none. The primary outcome was a composite of acute kidney injury, elevated troponin, elevated B-type natriuretic peptide, stroke, or death. Secondary outcomes included return to operating room, hospital length of stay, and hypotension. Patient characteristics were compared using χ2 and Wilcoxon tests. Propensity scores were estimated using age, sex, and hypertension history, and inverse propensity score weighting (IPSW) was applied to univariate and multivariable outcome models. RESULTS: IV nicardipine was administered to 1207 patients (60.4%). These patients had higher rates of preexisting hypertension (60% vs 37%, P < .01), longer operative times (median 279 vs 251 minutes, P < .01), and longer hospital stays (median 105 vs 80 hours, P < .01). On univariate analysis, the composite outcome (11% vs 7%, P < .01) and return to the operating room (2% vs 0%, P < .01) were more frequent in the nicardipine group. In IPSW-weighted multivariable analyses, IV nicardipine remained associated with the composite primary outcome (odds ratio = 1.32; 95% CI, 1.05-1.68; P = .02). Nicardipine use was independently associated with prolonged hospital length of stay (β = 32.68; 95% CI, 16.1-49.25; P = .001). CONCLUSION: Among patients undergoing craniotomy with an institutional postoperative SBP target <140 mm Hg, patients requiring IV nicardipine had longer hospital stays and higher rates of systemic complications after IPSW-adjusted analysis.