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Updated: Jul 1, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Aggressive blood pressure-lowering treatment before intravenous tissue plasminogen activator therapy in acute
Sheryl Martin-Schild1, Hen Hallevi, Karen C Albright
1Vascular Neurology Program, Department of Neurology, University of Texas Health Science Center at Houston, 6431 Fannin St, Medical School Bldg Room 7.128, Houston, TX 77030, USA. Sherylmartinschild@yahoo.com
Insights
Lowering high blood pressure before administering tissue plasminogen activator (tPA) for acute ischemic stroke (AIS) appears safe. Aggressive BP management did not increase hemorrhage or poor outcomes, suggesting patients shouldn't be excluded from tPA.
Area of Science:
- Neurology
- Cardiology
- Emergency Medicine
Background:
- Elevated blood pressure (BP) is common in acute ischemic stroke (AIS).
- Current guidelines suggest withholding intravenous tissue plasminogen activator (tPA) if aggressive BP lowering is needed.
- The impact of BP management on tPA outcomes in AIS requires further evaluation.
Purpose of the Study:
- To assess the safety and outcomes of AIS patients requiring BP management before tPA.
- To compare outcomes between aggressive nicardipine treatment and labetalol for pre-tPA BP control.
Main Methods:
- Retrospective review of 178 AIS patients treated with intravenous tPA within 3 hours of onset.
- Analysis of BP management strategies, including nicardipine and labetalol.
- Evaluation of symptomatic intracerebral hemorrhage and neurologic deterioration rates.
Main Results:
- Fifty patients (28%) required BP lowering before tPA.
- Nicardipine was used in 24 of these patients, either as first-line or after labetalol.
- No significant differences in adverse events or modified Rankin score were observed between patients requiring BP lowering and those who did not.
Conclusions:
- Pre-tPA BP lowering, even with aggressive methods, is not associated with increased hemorrhage or poor outcomes in AIS.
- Patients with AIS requiring aggressive BP management should not be excluded from tPA therapy.
- Prospective studies are warranted to confirm these findings.
Background:
Patients with acute ischemic stroke (AIS) commonly have elevated blood pressure (BP). Guidelines have recommended against treatment with intravenous tissue plasminogen activator (tPA) when aggressive measures such as continuous infusion with nicardipine hydrochloride are required to maintain BP lower than 185/110 mm Hg. We evaluated the effect of elevated BP and its management on clinical outcomes after tPA therapy in AIS.
Objectives:
To evaluate safety and outcome in patients with AIS who require treatment to lower BP before tPA therapy and to compare safety and outcome in patients who received aggressive treatment with nicardipine with those who received labetalol hydrochloride before tPA.
Design:
Retrospective review of medical records for all patients who received intravenous tPA within 3 hours of AIS onset.
Setting:
Emergency department. Patients One hundred seventy-eight patients with AIS treated with tPA.
Main Outcome Measures:
Occurrence of symptomatic intracerebral hemorrhage and neurologic deterioration.
Results:
Fifty patients required BP lowering before tPA therapy. Twenty-four of these patients (48%) received nicardipine either after labetalol or as first-line therapy. Patients requiring antihypertensive agents had higher baseline blood glucose concentrations, incidence of hypertension, and National Institutes of Health Stroke Scale scores. The rate of adverse events and of modified Rankin score at discharge were not significantly different in patients without BP-lowering treatment compared with patients given either labetalol or nicardipine before intravenous tPA therapy.
Conclusions:
Blood pressure lowering before intravenous tPA therapy, even using aggressive measures, may not be associated with a higher rate of hemorrhage or poor outcome. Data suggest that patients with AIS requiring aggressive treatment to lower BP should not be excluded from receiving tPA therapy. A prospective study is needed to support these conclusions.
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