Blood Pressure Management in CVA

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May 8, 2018 by dailybolusoflr

By: Derrick Ashong


Hypertensive Emergency Ischemic Stroke w/ TPA Treatment (IV or IA)A Ischemic Stroke w/o TPA treatment Hemorrhagic Stroke  Ischemic Stroke with Hypotension Hemorrhagic Stroke with Hypotension
25% MAP reduction over 1 hour SBP <185 mmHg

DBP <110

<220 mmHg <160 mmHg (if SBP >180) Find underlying cause Find underlying cause


  140 or 160 mmHg (if SBP 150-220 Hg)** Ex. Hypovolemia, sepsis, cardiac Ex. Hypovolemia, sepsis, cardiac
  15% reduction*   <160 mmHg (if aneurysmal hemorrhage) Sustained SBP <130-150 with deterioration in neurologic status*** Sustained SBP <130-150 with deterioration in neurologic status ***


*15% reduction: Consider in patients with complicating medical conditions that may necessitate BP reduction for management, like ACS, decompensated heart failure or aortic dissection

**Based largely on consensus, expert opinion

**Reflects uncertainty around right-shifted autoregulatory limits (INTERACT-2, ATACH, ATACH-2 trials).  The guidelines do not recommend acutely decreasing severely elevated BPs.  Recent studies argue for <180 mmHg.

*** A LOT of controversy regarding this.  Most studied pressor for these patient’s if need be is phenylephrine


Cerebral autoregulation is the process by which cerebral blood flow remains relatively constant despite increases or decreases in systemic blood pressure. Cerebrovascular resistance adapts to changes in perfusion pressure to maintain constant cerebral blood flow. When blood pressure exceeds the upper limit of autoregulation, there is resultant cerebral edema and blood-brain barrier dysfunction. When blood pressure decreases below the lower autoregulation limit, there can be decreased perfusion, with worsening ischemia and stroke progression.


Management of Hypertension in Stroke, Miller, Joseph et al., Annals of Emergency Medicine , Volume 64, Issue 3, 248 – 255

Blood pressure management in stroke. Anne L. Donovan; Alana M. Flexman; Adrian W. Gelb, Current Opinion in Anaesthesiology. 25(5):516–522, OCT 2012

Potter JF1, Robinson TG, Ford GA, Mistri A, James M, Chernova J, Jagger C. Controlling hypertension and hypotension immediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol. 2009 Jan;8(1):48-56. doi: 10.1016/S1474-4422(08)70263-1. Epub 2008 Dec 4.


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