Autonomic dysfunction and hemodynamic management after acute spinal cord injury: blood pressure targets, perfusion strategies, and emerging therapies.

Objective: Acute spinal cord injury (SCI) produces profound cardiovascular instability that exacerbates secondary damage, emphasizing the need for timely blood pressure management and hemodynamic support. While stabilizing hemodynamics is central to acute SCI management, evidence guiding optimal mean arterial pressure (MAP) targets, vasopressor selection, and management strategies remains limited. We conducted a narrative, comprehensive review of peer-reviewed clinical and preclinical studies addressing hemodynamic management after SCI, defined here as the first 7 days after injury, including MAP augmentation, spinal cord perfusion pressure (SCPP) monitoring, vasopressor selection, and neuromodulatory approaches. Results: Observational studies show that even transient hypotensive episodes within the first 72 h worsen neurological recovery. Updated guidelines recommend maintaining MAP between 75 to 80 and 90 to 95 mmHg for 3 to 7 days following injury. Norepinephrine is favored as first-line therapy because it reliably raises MAP with fewer adverse effects than other vasopressors. Neuromodulation with tSCS or eSCS has been shown to restore blood pressure and stabilize cardiovascular control in chronic SCI. Emerging evidence suggest these neuromodulatory approaches may be adapted for acute care. SCPP-guided strategies using lumbar cerebrospinal fluid drainage or direct intraspinal monitoring better reflect local perfusion and predict outcomes more accurately than MAP alone, although their use is limited to specialized centers. Conclusion: Hemodynamic management after SCI should be considered a therapeutic intervention that directly modifies secondary injury mechanisms. Refining MAP targets, expanding access to SCPP-guided care, and evaluating staged neuromodulation, could enhance precision and individualized care to improve long-term recovery. Large-scale multicenter trials will be essential to establish protocols that improve both neurological and cardiovascular outcomes after SCI.