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R e v i e w P a p e r

Blood Pressure Control in Acute

Cerebrovascular DiseaseWilliam B. Owens, MD

Acute cerebrovascular diseases (ischemic stroke,intracerebral hemorrhage, and subarachnoid

hemorrhage) affect 780,000 Americans each year.Physicians who care for patients with theseconditions must be able to recognize when acutehypertension requires treatment and shouldunderstand the principles of cerebralautoregulation and perfusion. Physicians shouldalso be familiar with the various pharmacologicagents used in the treatment of cerebrovascularemergencies. Acute ischemic stroke frequently

presents with hypertension, but the systemicblood pressure should not be treated unless thesystolic pressure exceeds 220 mm Hg or thediastolic pressure exceeds 120 mm Hg. Overlyaggressive treatment of hypertension cancompromise collateral perfusion of the ischemic

penumbra. Hypertension associated withintracerebral hemorrhage can be treated moreaggressively to minimize hematoma expansionduring the first 3 to 6 hours of illness.Subarachnoid hemorrhage is usually due toaneurysmal rupture; systolic blood pressureshould be kept

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volume of >60 mL were found by Broderick andcolleagues to have a 30-day mortality of 90%,while those with a hematoma volume of

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making it a desirable agent in the treatment ofuncontrolled hypertension during cerebrovascularemergencies.38 Bradycardia may occur and labetalolis generally not given if the heart rate is

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evidence that SNP may be deleterious in patientswith cerebrovascular emergencies and uncontrolledhypertension. SNP is a potent dilator of both arteri-oles and veins, which can lead to increased cerebraledema and intracranial pressure.40 In addition,renal or hepatic dysfunction can lead to impairedmetabolism and accumulation of toxic levels of

cyanide and thiocyanate.11,37 Given the ready avail-ability of safer alternatives, sodium nitroprussideshould not be used in the treatment of hypertensionassociated with cerebrovascular disease.

CONCLUSIONSAcute cerebrovascular diseases are common events,and physicians should be comfortable with managingBP derangements in these patients. Above all, thetreating physician should ensure that hypoxemia andcerebral hypoperfusion are avoided, as this can resultin significant secondary brain injury. When uncon-

trolled hypertension is present, the physician mustdecide two things: one, what is the optimal BP for thispatient; and two, what is the best pharmacologicagent to reach this goal. Prompt treatment, whileavoiding exacerbating cerebral ischemia, is an inte-gral part of the care of patients with acute cerebrovas-cular disease.

Disclosures: The author reports no financial or proprietaryinterests in any of the subject matter discussed in this manu-script. No financial support for this paper has been obtained.

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