Treatment of Hypertensive Emergency in Acute Ischaemic Stroke Eligible for or Treated with Reperfusion Therapy

When acute ischaemic stroke is complicated by hypertensive emergency in a patient who is a candidate for — or has already received — reperfusion therapy (intravenous thrombolysis or mechanical thrombectomy), blood pressure management becomes a time-critical clinical priority with distinct thresholds and timing requirements.

Clinical Scenario

This protocol addresses acute ischaemic stroke patients who are eligible for, or are being treated with, reperfusion therapy — either intravenous thrombolysis or mechanical thrombectomy. In this setting, elevated blood pressure must be managed according to a structured approach that accounts for the reperfusion procedure itself and the critical post-treatment window.

Treatment Approach

Management centres on careful, controlled blood pressure lowering, with the timing and target of BP reduction differing between the pre-procedure phase (before thrombolysis) and the post-treatment maintenance period. The approach for patients undergoing intravenous thrombolysis is specifically differentiated from the broader reperfusion therapy guidance.

The complete structured regimen — including the full sequence, agents, and decision algorithm — is available via the link below.

Treatment Targets

Systolic BP <185 mmHg and diastolic BP <110 mmHg prior to thrombolysis
BP maintained at <180/105 mmHg over the first 24 hours after treatment

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1093/eurheartj/ehae178

In patients who are eligible for re-perfusion therapy with intravenous thrombolysis or mechanical thrombectomy, BP should be carefully lowered and maintained at <180/105 mmHg for at least the first 24 h after treatment.
In patients undergoing treatment with i.v. thrombolysis, BP should be lowered to <185/110 mmHg prior to thrombolysis and then maintained at <180/105 mmHg over the following 24 h.

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