The present recommendation is to not treat hypertension in most patients with ischaemic stroke, unless blood pressure exceeds 200 mm Hg to 220 mm Hg (systolic) or 120 mm Hg to 140 mm Hg (diastolic).
Alteplase should only be given if the blood pressure is lower than 185 mm Hg (systolic) and 105 mm Hg to 110 mm Hg (diastolic).
Patients with primary intracerebral haemorrhage can be treated with antihypertensive drugs if systolic blood pressure is higher than 180 mm Hg to 200 mm Hg, if diastolic blood pressure exceeds 105 mm Hg, or if mean arterial pressure is higher than 130 mm Hg to 150 mm Hg.
Current guidelines do not support interventions to increase blood pressure in patients with acute ischaemic stroke.
In patients with acute stroke, blood pressure should be reduced gradually with special attention for possible contraindications. The decrease in blood pressure shouldnot exceed 10–20% of the initial level because of the higher set point of the autoregulation of cerebral blood flow in hypertensive patients and to avoid the risk of poor perfusion of aff ected brain area.
Indications to actively lower blood pressure are haematoma growth or rebleeding in primary intracerebral haemorrhage, or coexisting critical conditions, such as hypertensive encephalopathy, aortic dissection, heart failure, acute myocardial infarction, acute renal failure, or preeclampsia and eclampsia.
Blood pressure as a prognostic factor after acute stroke. Tikhonoff V, Zhang H, Richart T, Staessen JA. Lancet Neurol. 2009 Oct;8(10):938-48.
