Acute Blood Pressure Management

Acute hypertensive response is commonly encountered in the acute phase of ischemic stroke, affecting both previously hypertensive and normotensive patients. Different pathophysiological mechanisms may lead to elevated blood pressure levels, such as an abnormal autonomic response, which may be either stress-related—due to the direct cerebral insult—or as a compensatory mechanism to maintain sufficient cerebral blood flow. Irrespective of the underlying mechanisms, post-stroke hypertension has been independently associated with adverse clinical outcomes in stroke patients. Higher mortality rates and lower functional independence rates have been observed in relation to high blood pressure levels. Additionally, in the patients receiving reperfusion therapies, post-stroke hypertension has also been correlated with a higher likelihood of symptomatic intracranial hemorrhage and lower recanalization rates. Nevertheless, the optimal management of arterial blood pressure after an acute ischemic stroke has not been yet delineated. Important considerations, such as the optimal target range of blood pressure that should be maintained or the most appropriate antihypertensive agents to be used, still remain unanswered. In this chapter, we aim to discuss the available evidence regarding blood pressure management in different acute ischemic stroke settings: prehospital management, management of patients who are ineligible for reperfusion treatments, patients receiving intravenous thrombolysis, and patients treated with mechanical thrombectomy.