Acute Blood Pressure Management in Acute Ischemic Stroke and Spontaneous Cerebral Hemorrhage

We discuss the evidence and guidelines for acute blood pressure (BP) management for patients presenting with acute ischemic stroke or spontaneous cerebral hemorrhage.

Observational data suggest that the extremes of BP should be avoided in patients presenting with acute ischemic stroke. There is no convincing evidence that active BP reduction results in improved outcomes for ischemic stroke patients. Current guidelines recommend that BP be maintained ≤ 185/110 mmHg in patients who are candidates for intravenous tissue plasminogen activator (IV tPA) or mechanical thrombectomy and that BP be maintained ≤ 180/105 mmHg for at least 24 h in patients who have received IV tPA or have undergone mechanical thrombectomy. Acute BP goals for spontaneous cerebral hemorrhage remain unclear despite a number of randomized controlled trials. Acute BP goals for patients with acute ischemic stroke largely depend on candidacy for, and receipt of, IV tPA and mechanical thrombectomy. As thrombectomy is now the standard of care for many patients with large vessel occlusion, we will see a heightened interest in pre- and post-thrombectomy BP management. Future trials of spontaneous cerebral hemorrhage may focus on hyperacute BP lowering (e.g., in the prehospital setting).