Management of Hypertension in the Acute Phase of Stroke

An increase in arterial blood pressure (BP) is common following the onset of stroke. Although there is evidence suggesting that this acute elevation of BP is associated with a poor clinical outcome in both ischemic and hemorrhagic stroke patients, optimal treatment strategies are currently unknown. The management of BP in the first 24 hours following stroke lends itself to two competing rationales in both stroke sub-types. In ischemic stroke patients, BP reduction may improve outcome, potentially by reducing hemorrhagic transformation and edema formation. Conversely, antihypertensive therapy may also reduce cerebral blood flow (CBF) in the penumbra, exacerbating ischemic injury. Similarly, BP reduction may improve outcome in hemorrhagic stroke patients by preventing the expansion of the hematoma and reducing perihematoma edema. The perihematoma region has also been hypothesized to have ischemic penumbral properties, although the evidence for this is limited. Nonetheless, there is the potential for detrimental CBF compromise following BP reduction in hemorrhagic stroke as well. Recently, advanced neuro-imaging techniques have made it possible to test many of the hypotheses related to the etiology of BP elevation and optimal treatment strategies in acute stroke. This article summarizes concepts and evidence for different BP management strategies in both types of stroke.