What is the target map for the acute management of ischemic stroke?

Target MAP in Acute Ischemic Stroke

Blood Pressure Management Strategy

In acute ischemic stroke, there is no specific target MAP (mean arterial pressure); instead, blood pressure management is guided by systolic and diastolic thresholds that differ based on whether the patient is receiving reperfusion therapy. 1, 2

For Patients Eligible for Reperfusion Therapy (IV rtPA or Thrombectomy)

Pre-Treatment Requirements

• Blood pressure must be reduced to <185/110 mmHg before administering IV rtPA 1, 2
• Acceptable agents for rapid BP reduction include:
  • Labetalol 10-20 mg IV over 1-2 minutes, may repeat once 1
  • Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes to maximum 15 mg/h 1
  • Other agents such as clevidipine may be considered 2
• If blood pressure cannot be maintained at or below 185/110 mmHg, do not administer rtPA 1

During and After Reperfusion Therapy

• Maintain blood pressure ≤180/105 mmHg for 24 hours after thrombolysis or mechanical thrombectomy 1, 2, 3
• Monitor BP every 15 minutes for 2 hours from start of rtPA, then every 30 minutes for 6 hours, then hourly for 16 hours 1, 3
• If systolic BP rises to 180-230 mmHg or diastolic BP 105-120 mmHg:
  • Labetalol 10 mg IV followed by continuous infusion 2-8 mg/min 1
  • Nicardipine 5 mg/h IV, titrate to desired effect 1
• If diastolic BP >140 mmHg, consider IV sodium nitroprusside 1

For Patients NOT Receiving Reperfusion Therapy

Conservative Approach to Hypertension

• Only consider lowering blood pressure if systolic BP >220 mmHg or diastolic BP >120 mmHg 1, 2
• A reasonable target is to lower blood pressure by 15-25% within the first day 1
• The rationale: cerebral autoregulation is impaired during acute stroke, and the brain may depend on elevated systemic pressure to maintain perfusion to the penumbra 1, 4

Exceptions Requiring BP Reduction

Consider blood pressure reduction for concomitant conditions regardless of stroke type:

• Acute myocardial infarction 1
• Acute heart failure 1
• Acute aortic dissection 1

Critical Pitfalls to Avoid

• Overly aggressive blood pressure lowering in non-thrombolysis candidates can worsen cerebral perfusion and expand the infarct 1, 4
• Inadequate BP control before or during thrombolysis significantly increases the risk of symptomatic intracranial hemorrhage 3, 4
• Arterial hypotension (systolic <100 mmHg) is rare but dangerous in acute stroke, suggesting alternative diagnoses like cardiac ischemia, aortic dissection, or shock, and requires immediate investigation and correction 1
• Failure to monitor BP frequently during the acute phase can miss dangerous fluctuations requiring intervention 1

Practical Algorithm

1. Determine reperfusion eligibility immediately 2, 3
2. If eligible for rtPA/thrombectomy:
   • Target <185/110 mmHg pre-treatment 1, 2
   • Target ≤180/105 mmHg during and for 24 hours post-treatment 1, 3
3. If NOT eligible for reperfusion:
   • Permissive hypertension up to 220/120 mmHg 1, 2
   • Only treat if exceeding these thresholds or if other organ injury present 1