Blood Pressure Management in Acute Stroke Care

Acute stroke care demands careful modulation of blood pressure to balance the risks of further cerebral injury against the dangers of hypoperfusion. Elevated arterial pressure is a common physiological response after both ischaemic and haemorrhagic stroke, yet the optimal strategy for intervention remains debated. In ischaemic stroke, mildly elevated pressures may support collateral perfusion of the penumbra, the zone of potentially salvageable tissue surrounding the infarct core. Excessive blood pressure, however, risks haemorrhagic transformation, cerebral oedema and secondary injury. In intracerebral haemorrhage, rapid reduction of systolic pressure aims to limit haematoma expansion and prevent neurological deterioration. Contemporary practice emphasises individualised targets informed by stroke subtype, time from onset, premorbid blood pressure and planned reperfusion therapies. Key considerations include the timing of intervention—prehospital, hyperacute (<6 hours) or early in-hospital phases—the choice of antihypertensive agents with favourable cerebral haemodynamic profiles, and continuous monitoring to avoid undue fluctuations. As endovascular thrombectomy and intravenous thrombolysis become widespread, integration of blood pressure management into multimodal reperfusion protocols is essential. Ongoing research seeks to refine thresholds, identify patient subgroups most likely to benefit, and explore novel approaches to stabilise haemodynamics in those at highest risk of secondary injury.

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Blood Pressure Management in Acute Stroke Care publication trend

The graph below shows the total number of articles in blood pressure management in acute stroke care across all publications each year (not limited to Nature Index journals).

Technical terms

Reperfusion: Restoration of blood flow to previously ischaemic brain tissue.

Endovascular thrombectomy: Mechanical removal of an intravascular clot via catheter-based techniques.

Modified Rankin Scale: Ordinal scale assessing functional outcome and degree of disability after stroke.

Collateral circulation: Network of secondary vessels that maintain cerebral perfusion when primary arteries are occluded.

Blood pressure variability: Fluctuations in arterial pressure over time, reflecting haemodynamic instability.

References

1. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomised, sham-controlled, blinded, phase 3 trial. The Lancet (2019).
2. Blood Pressure and Penumbral Sustenance in Stroke from Large Vessel Occlusion. Frontiers in Neurology (2017).
3. Acute post-stroke blood pressure relative to premorbid levels in intracerebral haemorrhage versus major ischaemic stroke: a population-based study. The Lancet Neurology (2014).
4. European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. European Stroke Journal (2021).
5. Management of Blood Pressure During and After Recanalization Therapy for Acute Ischemic Stroke. Frontiers in Neurology (2019).
6. Postreperfusion Blood Pressure Variability After Endovascular Thrombectomy Affects Outcomes in Acute Ischemic Stroke Patients With Poor Collateral Circulation. Frontiers in Neurology (2019).