Blood pressure management in an acute stroke

David Goldemund M.D.
Updated on 20/03/2024, published on 02/05/2023
  • high blood pressure (BP) is a common correlate of an acute stroke
  • except for hypertensive emergencies (hypertensive crisis) and hypertensive hemorrhage, high BP is usually a consequence rather than a cause of the acute neurological disorder
  • the cause of increased blood pressure is multifactorial and may include:
    • autoregulation trying to maintain adequate cerebral perfusion pressure (CPP)
    • stress reaction triggered by pain and fear
    • Cushing’s reaction (hypertension, bradycardia, and breathing disturbances) occurring in brainstem lesions or advanced intracranial hypertension with secondary brainstem compression
  • rapid and significant BP lowering may be counterproductive and have a negative impact on the outcome by decreasing CPP
    • except for hypertensive emergency, SAH, and ICH
  • preferred antihypertensive drugs in the acute phase include:  ENALAPRIL LABETALOL URAPIDIL
  • arterial blood pressure (BP) monitoring is a cornerstone of hemodynamic monitoring in neurocritical care
  • both hypotension and hypertension can can be detrimental to vital organ function and worsen the patient’s outcome
  • BP monitoring techniques include:
    • noninvasive BP monitoring (more common)
      • intermittent (using inflatable cuff) – the proper cuff size is critical for accurate readings
        • manual (auscultatory, palpatory)
        • automated (oscillometric)
      • continuous
        • volume clamp method
        • arterial applanation tonometry
    • invasive BP measurement via arterial cannulation (most commonly automated)
  • choice of BP monitoring method must be individualized
    • low-risk patients – intermittent oscillometric BP monitoring
    • high-risk, hemodynamically unstable patients – continuous BP monitoring (either noninvasive or invasive)
    • critically ill patients/hypertensive emergencies – continuous invasive BP monitoring via an arterial catheter is preferred

Proper cuff size

  • the cuff bladder length should be at least 80% of the upper arm circumference
    • arm circumference < 35 cm – choose cuff size 16×30 cm (suitable for most patients)
    • arm circumference 35-44 cm – cuff size 16×36 cm
    • arm circumference > 45 cm – cuff size 16×42 cm

Acute ischemic stroke

  • autoregulation is disrupted in the ischemic region (sometimes for weeks), and regional perfusion depends on systemic pressure (→ Regulation of cerebral perfusion)
  • both excessively high and low blood pressure (U-curve) are negative prognostic factors in acute stroke patients
  • see the table for management in the first 24-48 hours (as recommended by AHA/ASA 2021 and ESO 2021)
    • in general, higher blood pressure is beneficial
    • consider all comorbidities and factors that may require more aggressive BP correction
    • avoid excessive lowering when attempting to control BP prior to thrombolysis
  • routine blood pressure lowering in the prehospital setting is generally not recommended (the INTERACT4 trial)
  • prehospital treatment with glyceryl trinitrate should be avoided (potential harm in ICH patients)
  • avoid sublingual nifedipine (may cause hypotension)
  • in neurologically stable patients with BP >140/90 mm Hg, peroral (PO) therapy should be resumed within 48-72 hour
    • it is unclear whether chronic PO therapy should be discontinued  (ESO 2021)
    • in patients with dysphagia, wait for improvement or place a nasogastric tube
Mechanical thrombectomy with or without IVT
  • target BP after recanalization therapy depends on several factors, including the individual’s age, medical history, and the extent of the stroke
  • target BP < 185/110 mmHg before IVT/MT
    • avoid excessive lowering when trying to control BP prior to IVT
  • target BP < 180/105 mmHg for the next 24 h after IVT/MT (AHA/ASA 2019 I/C)  → see thrombolytic protocols

    • the optimal BP target after mechanical recanalization without IVT remains unclear
  • avoid hypotension periods
  • induced hypertension is not recommended after a successful thrombectomy (TICI 3) (ESO 2021)
Conservative therapy
  • patients with BP < 220/110 mmHg without comorbidities requiring BP correction – routine BP correction in the first 24 h is not suggested  (ESO 2021) (AHA/ASA 2019 III/A)
  • patients with BP ≥ 220/110 mmHg without comorbidities requiring BP correction – the benefit of BP correction is unknown; a 15% reduction in the first 24h is reasonable and probably safe  (ESO 2021 expert consensus) (AHA/ASA 2019 IIb/C-EO)
  • patients with neurological deterioration:
    • routine use of vasopressors to increase BP and improve perfusion is not recommended
    • if the deterioration is caused by the hypoperfusion (confirmed by low intracranial flow on TCCD), it is suggested to:
      • discontinue antihypertensive therapy
      • increase intravenous fluid intake
      • use nonpharmacologic methods to increase blood pressure
      • finally, consider the use of vasopressors
  • more aggressive treatment of BP in the acute phase is indicated in case of relevant comorbidities (hypertensive emergency)  (AHA/ASA 2019 I/C-EO)
    • pre-/eclampsia
    • left-sided heart failure
    • acute coronary syndrome (ACS)
    • aortic dissection
    • hypertensive encephalopathy
    • concomitant SAH or cerebral aneurysm

according to AHA/ASA 2019 and ESO 2021

Intracerebral hemorrhage

  • on admission, check BP every 5-10 minutes or start invasive BP monitoring
  • aggressive and rapid treatment of hypertension is an essential therapeutic approach (along with correction of coagulopathy)
    • high BP is associated with an increased risk of hematoma progression with worse clinical outcome
    • initiating treatment within 2 hours of ICH onset and achieving the target within 1 hour may be useful to reduce the risk of hematoma expansion and improve functional outcome (AHA/ASA 2022, 2a/C-LD)
    • ischemia around the hematoma plays a minor role (except perhaps in large hematomas), and BP reduction seems safe
  • continue with chronic PO medications if possible; if dysphagia or decreased LOC is present, use parenteral therapy or place a nasogastric (NG) tube
  • in patients with known hypertension, the target BP may be higher due to altered autoregulation with the risk of decreased CPP
  • nitroprusside is not recommended due to its potential to increase intracranial pressure (ICP)
  • smooth and sustained control of BP is required; avoid sudden drops or peaks in BP and maintain Mean Arterial Pressure (MAP) >85 mm Hg
  • if the ICP is monitored, then correct BP to maintain CPP 60-80 mm Hg
Initial systolic blood pressure (SBP) 150-220 mm Hg in patients with ICH of mild-to-moderate severity
  • target SBP ≤ 140 mm Hg (ESO guidelines 2021)  (AHA/ASA 2022 2b/B-R)
    • lowering SBP to 140 mm Hg is safe and may reduce hematoma expansion and lead to improved outcomes
    • maintain in the range of 130-150 mm Hg
    • target <140 mm Hg was used in the INTERACT3 trial
  • no significant clinical benefit of lowering < 140 mmHg was demonstrated
    • In the INTERACT2  trial, there were fewer patients with mRS 3-6 in the intensive treatment group (SBP<140 mm Hg) compared with the standard treatment group (SBP <180 mm Hg);  the difference was not statistically significant
    • the benefit of lowering SBP <140 mm Hg was not demonstrated in the ATACH-2 trial – lowering SBP <120 mm Hg may even be harmful
  • acute lowering of SBP to <130 mm Hg is potentially harmful (AHA/ASA 2022 3/B-R)
  • start antihypertensive treatment ASAP (ideally within 2 hours of symptom onset)
  • the reduction of SBP should not exceed 90 mm Hg from baseline values  (ESO guidelines 2021)

    • greater BP reduction was significantly associated with acute kidney injury regardless of preexisting CKD  (Burgess, 2018)
Initial SBP > 220 mmHg or large hematoma
  • limited data on the safety and efficacy of a target SBP ≤ 140 mm Hg
  • SBP reduction should not exceed 90 mmHg from the baseline
  • cautious BP lowering is required in these patients ⇒  maintain CPP > 6070 mm Hg

Subarachnoid hemorrhage

  • start noninvasive continuous BP monitoring immediately; in severe SAH or fluctuating BP, invasive monitoring is preferred
  • BP control in SAH is complex; as there are reasons to both lower BP (to decrease risk of rebleeding) and raise BP (to decrease the risk of delayed ischemic deficits)
  • with an untreated source of bleeding, the aim is to maintain SBP ≤ 130-140 mm Hg
    • 150-175 mm Hg postoperatively (⇒  ↑ CPP)
  • in the presence of cerebral vasospasms and a secured aneurysm, the target SBP is ~ 180-220 mm Hg to improve cerebral perfusion
  • excessive and rapid BP correction may be harmful (may lead to ↓CPP ⇒ risk of ischemia due to vasospasm)
  • avoid nitrates if possible, as they may increase intracranial pressure (ICP)

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Blood pressure management in an acute stroke