What is the recommended Mean Arterial Pressure (MAP) range for patients with ischemic stroke?

Blood Pressure Management in Acute Ischemic Stroke

For patients with acute ischemic stroke NOT receiving reperfusion therapy, maintain permissive hypertension and avoid treating blood pressure unless systolic BP exceeds 220 mmHg or diastolic exceeds 120 mmHg during the first 48-72 hours. 1, 2

MAP Targets Based on Clinical Scenario

Patients NOT Receiving Reperfusion Therapy

Permissive Hypertension Strategy (First 48-72 Hours):

• Do not treat BP if systolic <220 mmHg or diastolic <120 mmHg 1, 2, 3
• If BP ≥220/120 mmHg, reduce mean arterial pressure by only 15% over 24 hours 1, 2
• This translates to maintaining MAP typically between 90-140 mmHg without intervention 1
• Optimal systolic BP range based on outcomes data: 121-200 mmHg (corresponding to MAP approximately 90-140 mmHg) 4, 1

Rationale: Cerebral autoregulation is impaired in the ischemic penumbra, making cerebral blood flow directly dependent on systemic perfusion pressure. 1, 2 The brain requires elevated BP to maintain collateral flow to potentially salvageable tissue. 4, 1

Patients Receiving IV Thrombolysis

Strict BP Control Required:

• Before thrombolysis: Lower BP to <185/110 mmHg (MAP <135 mmHg) 4, 1, 2
• During and after thrombolysis: Maintain BP <180/105 mmHg (MAP <130 mmHg) for at least 24 hours 4, 1, 2, 5
• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 4

Rationale: Higher BP increases risk of hemorrhagic transformation after thrombolysis, requiring more aggressive control to balance reperfusion benefits against bleeding risk. 1, 5

Patients Receiving Mechanical Thrombectomy

Pre-procedure targets:

• Maintain BP <185/110 mmHg (MAP <135 mmHg) before the procedure 4, 1
• If patient also received IV thrombolysis, follow the stricter thrombolysis protocol above 4

Post-procedure monitoring:

• Check BP every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly for 16 hours 4
• Maintain systolic BP <180 mmHg (MAP approximately <120-130 mmHg) 4

After the Acute Phase (>48-72 Hours)

Transition to Secondary Prevention:

• Initiate or restart antihypertensive medications in neurologically stable patients with BP ≥140/90 mmHg after 3 days 4, 2
• Target BP <130/80 mmHg for long-term secondary prevention 4, 2
• Use ACE inhibitors combined with thiazide diuretics as preferred agents 4

Management of Hypotension (Critical Pitfall)

Hypotension is a medical emergency in acute ischemic stroke and requires immediate correction:

• Maintain systolic BP >140 mmHg to ensure adequate cerebral perfusion 6
• Administer rapid volume replacement with 0.9% normal saline as first-line treatment 6
• Never use hypotonic solutions (5% dextrose or 0.45% saline) as they worsen cerebral edema 6
• Evaluate for cardiac causes (arrhythmias, myocardial infarction) with continuous monitoring and 12-lead ECG 6

Pharmacological Agents for Hypertension Control

Preferred agents when BP lowering is required:

• Labetalol: 10-20 mg IV over 1-2 minutes, may repeat once 4, 1
• Nicardipine: 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h 4, 1, 3
• Clevidipine: 1-2 mg/h IV, titrate by doubling dose every 2-5 minutes, maximum 21 mg/h 4

Agents to avoid:

• Sodium nitroprusside: Adversely affects cerebral autoregulation and increases intracranial pressure 1, 3
• Sublingual nifedipine: Causes precipitous BP drops that cannot be titrated 1

Critical Pitfalls to Avoid

Overly aggressive BP lowering is dangerous:

• Rapid BP reduction extends infarct size by reducing perfusion to the penumbra 1
• Even lowering BP to levels within the hypertensive range can be detrimental if done too quickly 1
• Studies show that decreases in BP during acute stroke are associated with poor outcomes 4
• A U-shaped relationship exists between BP and outcomes, with both extremes being harmful 4, 1

Do not reflexively treat elevated BP:

• Elevated BP may represent a compensatory response to maintain cerebral perfusion 1
• Treating BP <220/120 mmHg in non-reperfusion candidates during the first 48-72 hours worsens outcomes 1, 2

Monitor for volume depletion:

• Most stroke patients are euvolemic or hypovolemic due to pressure natriuresis 6
• Maintenance fluid requirements: approximately 30 mL per kilogram body weight daily 6