Blood pressure management in an acute stroke

Vloženo 25.10.2019, poslední aktualizace 02.05.2022

  • elevated blood pressure (BP) is a common correlate of an acute stroke
  • except for hypertensive encephalopathy and hypertonic hemorrhage, high BP is a consequence and not a cause of the acute neurological disorder
  • the cause of hypertension is multifactorial:
    • autoregulation trying to ensure sufficient CPP
    • stress response to pain and fear
    • the so-called Cushing’s reaction (hypertension, bradycardia, and breathing disturbances) in brainstem lesions or advanced intracranial hypertension with secondary brainstem compression
  • rapid and significant lowering of BP (except for hypertensive encephalopathy, SAH, and ICH) may be counterproductive, with a negative effect on outcome (due to a decrease of CPP)
  • preferred antihypertensive drugs in the acute stage: urapidil, labetalol, and enalapril

Acute ischemic stroke

  • autoregulation is disturbed in the ischemic region (sometimes for weeks), and regional perfusion depends on systemic pressure (regulation of cerebral perfusion)
  • too high or too low BP belongs to negative prognostic factors in acute stroke patients
    • there is a risk of hypoperfusion or, conversely, HEB damage and progression of edema or hemorrhagic transformation
  • see table for management in the first 24-48 h (as recommended by AHA/ASA 2021 and ESO 2021), especially considering all comorbidities and factors that will require more aggressive BP correction
  • routine blood pressure lowering in the pre-hospital setting is generally not recommended (ESO 2021
  • prehospital treatment with glyceryl trinitrate should be avoided (potential harm in ICH patients)
  • in neurologically stable patients with BP >140/90 mm Hg, restart PO therapy within 48-72 hours
    • it is unclear whether to discontinue chronic PO medication (ESO 2021)
    • in patients with dysphagia, wait until improvement or insert a NG tube
Mechanical thrombectomy with or without IVT
  • keep BP < 180/105 mmHg  before and during thrombolysis/MT and then for the following 24 h   → see thrombolytic protocols
  • reduction of SBP to ≤ 130 mmHg in the first 72h is not suggested; avoid periods of hypotension
  • induced hypertension is not recommended after successful MT (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 likely to be safe  (ESO 2021 expert consensus) (AHA/ASA 2019 IIb/C-EO)
  • in case of neurological deterioration:
    • routine use of vasopressors to increase BP and enhance perfusion is not recommended
    • if the deterioration is evidently caused by the hypoperfusion (e.g., low intracranial flow on TCCD), then it is suggested:
      • discontinue antihypertensive therapy
      • increase IV fluid intake
      • use non-pharmacological procedures to raise blood pressure
      • at last, consider the use of vasopressors
  • treatment of BP in the acute stage is indicated in case of relevant comorbidity (AHA/ASA 2019 I/C-EO)pre-/eclampsia
    • 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 (together with the correction of coagulation disorders)
    • high BP is associated with an increased risk of hematoma progression with worse clinical outcome
    • initiating treatment within 2 hours of ICH onset and reaching the target within 1 hour can be beneficial to reduce the risk of HE 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
  • if possible, continue with chronic PO medication; if dysphagia or decreased LOC are present, use parenteral therapy or insert a nasogastric (NG) tube
  • in patients with known hypertension, the target BP may be higher given altered autoregulation with the risk of CBF decrease
  • nitroprusside is not recommended because of the potential elevation of ICP
  • smooth and sustained control of BP is required; avoid sudden BP drops or peaks and maintain MAP >85 mmHg
  • if the intracranial pressure is monitored, then correct BP to keep CPP 60-80 mmHg
Initial systolic blood pressure (SBP) 150-220 mm Hg in patients with ICH of mild-to-moderate severity
  • target SBP ≤ 140 mmHg (ESO guidelines 2021)  (AHA/ASA 2022 2b/B-R)
    • lowering SBP to 140mmHg is safe and may reduce hematoma expansion and lead to improved outcomes
    • maintain in the range of 130-150 mm Hg
  • significant clinical benefit of a reduction < 140 mmHg has not been demonstrated
    • In the INTERACT2  trial, there were fewer patients with mRS 3-6 in the intensive treatment group (SBP<140 mmHg) compared to standard treatment (SBP <180 mmHg), but the difference was not statistically significant
    • the benefit of lowering SBP <140 mmHg was not demonstrated in the ATACH -2 randomized trial – lowering of 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 decrease of SBP should not exceed 90 mmHg from baseline values  (ESO guidelines 2021)

    • larger BP decrease was significantly associated with acute kidney injury regardless of preexisting chronic kidney disease  (Burgess, 2018)
Initial SBP > 220 mmHg or large hematoma
  • little data on the safety and effectiveness of a target threshold of SBP ≤ 140 mmHg
  • decrease of SBP should not exceed 90 mmHg from baseline values
  • cautious BP lowering is e required in these patients;  keep CPP > 6070 mmHg

Subarachnoid hemorrhage

  • immediately start non-invasive continuous BP monitoring; with severe SAH or fluctuating blood pressure, prefer invasive monitoring
  • BP control is complex for SAH because there are rationales for both BP lowering (↓ rebleeding risk ) and elevation (↓ risk of DID)
  • with an untreated source of bleeding, maintain SBP ≤ 130-140 mm Hg
    • postoperatively around 150-175 mm Hg (⇒ ↑ CPP)
  • in the presence of cerebral vasospasms in a patient with a secured aneurysm, the target SBP target is approx. 180-220 mmHg (to improve perfusion in the affected area)
  • excessive and rapid correction of BP can be damaging (↓CPP ⇒ risk of ischemia due to vasospasms)
  • avoid nitrates if possible (may elevate ICP)


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