Management of blood pressure in acute stroke

The importance of elevated or low arterial blood pressure (BP) early after stroke, and the need for pharmacological intervention to control BP, remains controversial. Debate surrounds if, when and how to intervene. This debate is informed by conflicting results from observational data and underpowered clinical trials and substantive outcome data are lacking. Accordingly, management decisions have largely been left up to the individual treating physician and guidelines are based on 'good practice' and theory rather than level 1, grade A evidence. Substantial progress has been made in recent years, particularly in the field of hemorrhagic stroke, where recently presented and soon to completed large-scale trials may finally give us a firm evidence base. For ischemic stroke, many important studies have informed our understanding of the basic pathophysiology, epidemiology, treatment and outcomes of BP management in acute stroke and, although not yet constituting a solid 'evidence base', are helping us from the 'cognitive quick-sand' of small studies and personal experiences.