Blood Pressure Management Before Intravenous Thrombolysis in Acute Ischemic Stroke: Rethinking Treatment Thresholds

Background Elevated blood pressure (BP) is common after acute ischemic stroke (AIS), but it is unclear if it should be lowered. Lowering elevated BP may compromise the ischemic brain, while the time taken to lower BP may delay or even exclude patients from receiving intravenous thrombolysis (IVT). Aim To review the rationale, guideline recommendations, and clinical evidence informing pre-IVT BP management, with a specific focus on patients presenting with a BP above the current guideline thresholds (BP ≥185/110 mmHg). Summary of review Cerebral autoregulation is impaired in AIS, both in the core and penumbra, creating vulnerability to harm from both excessive hypertension and BP reduction. Major trials of early or intensive BP-lowering in AIS (INTERACT4, MR-ASAP, and RIGHT-2) have either shown neutral or harmful effects with BP reduction. In the TRUTH study, a cluster-based observational comparison, centers that actively treated elevated BP before IVT achieved higher IVT rates but no better 90-day functional outcome, with a non-significant trend toward worse outcomes in the active-treatment arm. No randomized trial has helped define the optimal systolic BP target, speed of reduction, preferred antihypertensive agent, or balance of risks vs. benefits of BP reduction. prior to IVT. Conclusions Current practice on BP treatment prior to IVT is guided by historical thresholds and expert consensus rather than robust evidence. Major gaps persist with respect to causal associations, individualized treatment targets, and safe BP reduction strategies. Higher quality data are needed to establish evidence-based BP management for patients presenting ≥185/110 mmHg otherwise eligible for IVT, to uniform practice towards improved patient outcomes.