Purpose of Review <p>Effective control of blood pressure (BP) is potentially a critical determinant in making a successful recovery from acute ischemic stroke. BP is often elevated after the onset of this critical illness, and it is related to both the severity of the ischemic injury and subsequent changes in cerebral perfusion and collateral blood flow. However, recent studies have challenged longstanding assumptions over the safety and efficacy of BP lowering in being able to reduce the risk of reperfusion injury in acute ischemic stroke. This review synthesizes contemporary evidence and discusses the evolving landscape of BP management in acute ischemic stroke.</p> Recent Findings <p>Three prehospital ambulance-initiated trials of early BP lowering in patients with undifferentiated stroke have shown neutral or adverse effects, while the results of multiple trials of in-hospital management BP lowering in patients who have received successful reperfusion therapy for acute ischemic stroke due to large-vessel occlusion highlight the risks of over-aggressive treatment.</p> Summary <p>Despite considerable research effort, the optimal BP management strategy in acute ischemic stroke remains uncertain, although avoiding excessive reductions appears critical.</p>