What are the appropriate systolic blood pressure levels to maintain in cases of thrombotic and hemorrhagic strokes?

Blood Pressure Targets in Acute Stroke

No, your proposed thresholds are incorrect: for thrombotic (ischemic) stroke NOT receiving thrombolysis, you should only treat BP if it exceeds 220/120 mmHg (not maintain it at 220), and for hemorrhagic stroke, you should actively lower BP to a target of 140 mmHg systolic (not maintain it at 180). 1, 2

Blood Pressure Management in Acute Ischemic (Thrombotic) Stroke

For Patients NOT Receiving Thrombolysis or Thrombectomy

• Do not treat BP unless it exceeds 220/120 mmHg - permissive hypertension is the standard approach for the first 48-72 hours 1, 2
• If BP ≥220/120 mmHg: Lower BP carefully by approximately 15% (not more than 25%) over the first 24 hours 1
• Rationale: Cerebral autoregulation is impaired in acute stroke, making cerebral perfusion directly dependent on systemic BP - aggressive lowering can extend the infarct 1, 2

For Patients Receiving Thrombolysis (Alteplase)

• Before thrombolysis: BP must be lowered to <185/110 mmHg 1, 2
• After thrombolysis: Maintain BP <180/105 mmHg for at least 24 hours 1
• Preferred agents: Labetalol 10-20 mg IV over 1-2 minutes (may repeat) or nicardipine 5 mg/hr IV infusion 1, 2

After the Acute Phase (≥3 Days Post-Stroke)

• Initiate or restart antihypertensive therapy if BP remains ≥140/90 mmHg in stable patients 1, 2
• This is for long-term secondary prevention, not acute management 1

Blood Pressure Management in Hemorrhagic Stroke

Acute Intracerebral Hemorrhage

• Target systolic BP of 140 mmHg (achieved range typically 140-160 mmHg) if initial systolic BP is 150-220 mmHg 1
• Initiate treatment within 6 hours of symptom onset to reduce hematoma expansion 1
• Unlike ischemic stroke, there is no penumbra in hemorrhagic stroke, so BP reduction is generally well tolerated and beneficial 3

Critical Safety Consideration

• Avoid excessive acute drops in systolic BP >70 mmHg as this may cause acute renal injury and early neurological deterioration 1, 2

Key Pitfalls to Avoid

• Do NOT treat BP <220/120 mmHg in acute ischemic stroke (unless receiving thrombolysis) - this is ineffective and potentially harmful 1, 2
• Do NOT lower BP rapidly or aggressively - use easily titrated IV agents and avoid precipitous falls 1
• Do NOT forget to restart antihypertensive medications after 3 days in patients with pre-existing hypertension 1, 2
• Do NOT use the same BP targets for ischemic and hemorrhagic stroke - they require opposite approaches in the acute phase 1, 3