Early blood pressure management in acute ischaemic stroke before and after reperfusion treatment

Patients with acute ischaemic stroke often present with elevated blood pressure. Evidence has emerged that challenges the longstanding recommendation across clinical guidelines that blood pressure should be controlled to a systolic pressure of less than 185 mm Hg before initiating reperfusion therapy in these patients. RECENT: developments Major clinical trials (INTERACT4, MR-ASAP, and RIGHT-2) and an observational study (TRUTH) indicate that intensively lowering blood pressure before initiating reperfusion therapy for acute ischaemic stroke is associated with increased risk of death and disability. Similar evidence has reshaped our approach to blood pressure management in patients who receive successful endovascular thrombectomy for acute ischaemic stroke from large-vessel occlusion. The underlying mechanisms of cerebral ischaemia are likely to involve alterations in cerebral blood flow through collateral vessels and the microcirculation. WHERE: next? Current evidence underscores the harms of more intensive lowering of blood pressure to a systolic target of less than 140 mm Hg both before and after reperfusion therapy for acute ischaemic stroke. Despite the challenges in obtaining the necessary randomised evidence, such efforts are now required to establish whether elevated blood pressure should be controlled at all with this disease or left to decrease naturally.