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Purpose of Review <p>This review explores the literature guiding blood pressure (BP) management across three domains: acute ischemic stroke (AIS), intracranial hemorrhage (ICH), and subarachnoid hemorrhage (SAH). It aims to reinforce important physiologic mechanisms following stroke, summarize current guideline recommendations, and highlight areas of continued uncertainty and discordance.</p> Recent Findings <p>Emerging evidence reinforces that BP management must be tailored to stroke type, treatment eligibility, and individual factors. In AIS, recent data show no clear benefit to early, aggressive BP control in patients who are not thrombolytic candidates. Strict thresholds are still crucial for patients undergoing thrombolysis and thrombectomy. For ICH, newer trials have proposed that early lowering to systolic blood pressure (SBP) 130–150&#xa0;mmHg is safe and may improve functional outcomes, especially when conducted in bundled care pathways. Substantial BP variability and excessive BP lowering or “overshooting” (SBP &lt; 120&#xa0;mmHg) continue to be associated with harm. Randomized controlled trials (RCTs) in SAH remain limited, though gradual reduction to SBP 140–160&#xa0;mmHg and avoidance of large BP fluctuations are recommended to balance both re-bleeding and ischemia risks.</p> Summary <p>Optimal BP management in acute stroke necessitates an individualized, patient-centered approach that weighs both perfusion and risk of hemorrhage. Regardless of stroke type, preventing hypotension and large BP variability is essential. While research is ongoing to refine timing and methods of BP control, we propose adoption of bundled care pathways to standardize care and improve patient outcomes.</p>

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Blood Pressure Management in Acute Stroke

  • 期刊论文

  • 发表日期：

    2026年7月31日

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  • Cassidy Merklen,
  • Turner Miller,
  • Abigail Brackney

摘要

Purpose of Review

This review explores the literature guiding blood pressure (BP) management across three domains: acute ischemic stroke (AIS), intracranial hemorrhage (ICH), and subarachnoid hemorrhage (SAH). It aims to reinforce important physiologic mechanisms following stroke, summarize current guideline recommendations, and highlight areas of continued uncertainty and discordance.

Recent Findings

Emerging evidence reinforces that BP management must be tailored to stroke type, treatment eligibility, and individual factors. In AIS, recent data show no clear benefit to early, aggressive BP control in patients who are not thrombolytic candidates. Strict thresholds are still crucial for patients undergoing thrombolysis and thrombectomy. For ICH, newer trials have proposed that early lowering to systolic blood pressure (SBP) 130–150 mmHg is safe and may improve functional outcomes, especially when conducted in bundled care pathways. Substantial BP variability and excessive BP lowering or “overshooting” (SBP < 120 mmHg) continue to be associated with harm. Randomized controlled trials (RCTs) in SAH remain limited, though gradual reduction to SBP 140–160 mmHg and avoidance of large BP fluctuations are recommended to balance both re-bleeding and ischemia risks.

Summary

Optimal BP management in acute stroke necessitates an individualized, patient-centered approach that weighs both perfusion and risk of hemorrhage. Regardless of stroke type, preventing hypotension and large BP variability is essential. While research is ongoing to refine timing and methods of BP control, we propose adoption of bundled care pathways to standardize care and improve patient outcomes.