Blood Pressure In Acute Stroke Research Articles

The optimal management of arterial blood pressure in acute stroke: A never-ending conundrum

The optimal management of arterial blood pressure in acute stroke: A never-ending conundrum

Management of high blood pressure in acute stroke. What is the right answer?

Management of high blood pressure in acute stroke. What is the right answer?

Blood Pressure in Acute Stroke and Secondary Stroke Prevention.

Hypertension is common in patients presenting with stroke and is independently associated with unfavorable outcomes. This article reviews current guidelines for early management of blood pressure (BP) and highlights the findings of recent investigative works. Intensive blood pressure reduction after receiving alteplase has not been shown to improve outcomes. Patients with large vessel occlusions may benefit from lower blood pressure targets post-intervention. Retrospective analyses of large intracerebral hemorrhage trials suggest that specific subgroups of patients may disproportionately benefit from or be harmed by intensive BP reduction. Robust data for management of blood pressure in subarachnoid hemorrhage patients is lacking and expert consensus continues to guide decision-making. Despite the impact of hypertension on outcomes, most prospective trials assessing efficacy of blood pressure reduction have yielded neutral or inconclusive results. Further trials are necessary to determine which patient populations are most likely to benefit from blood pressure control.

Benefits and safety of transdermal glyceryl trinitrate in acute stroke: A systematic review and meta-analysis of randomized trials.

Transdermal glyceryl trinitrate (GTN) has potential beneficial properties in acute stroke including intracerebral hemorrhage (ICH) and possible clinical benefits suggested in ultra-early stroke (≤6h). Our meta-analysis updated the evidence on its safety and benefits in acute stroke. We searched major electronic databases for randomized trials comparing transdermal GTN versus placebo/control in acute stroke. Primary outcomes were mortality, 90-day modified Rankin Scale (mRS), and blood pressure (BP) effects. Secondary outcomes included early, late, resource utilization, and surrogate outcomes. Safety outcomes were adverse events. Reviewers identified studies, extracted data, and assessed risk of bias (RoB) using a modified Cochrane RoB instrument and quality of evidence (QoE) using GRADE. We also performed a priori subgroup and trial sequential analyses (TSA) on primary outcomes. These subgroup analyses were ICH versus ischemic stroke, minor (NIHSS ≤5) versus major (NIHSS >5) ischemic stroke, ischemic stroke with versus without thrombolysis, prehospital versus non prehospital settings, time from stroke to randomization ≤6h versus >6h, and high versus low overall RoB studies. Seven eligible primary trials enrolled 5363 patients. GTN reduced BP (mean difference [MD]=-4.74 mmHg, 95% confidence interval [CI]=-6.03 to -3.45mmHg] and diastolic BP (MD=-2.94 mmHg, 95% CI=-3.74 to -2.13mmHg) 24h posttreatment but did not affect 4- to 10-day mortality (relative risk [RR]=1.11, 95% CI=0.82 to 1.49), 90-day mortality (RR=0.96, 95% CI= 0.77 to 1.19), and 90-day mRS >2 (RR=0.98, 95% CI=0.93 to 1.03) compared to control/placebo. The QoE was high for primary outcomes with no subgroup effects detected. GTN did not affect secondary outcomes and increased risk of headache and hypotension. TSA generally supported our conclusions regarding primary outcomes. Transdermal GTN reduces BP in acute stroke but does not alter clinical outcomes even in ultra-early stroke (≤6h).

Insights into a personalized management of blood pressure in acute stroke.

Blood pressure management in acute stroke has long been a matter of debate. Epidemiological data show that high blood pressure is associated with death, disability and early stroke recurrence, whereas the pathophysiological rationale for ensuring elevated blood pressure in order maintain adequate cerebral perfusion remains a pertinent argument, especially in ischaemic stroke. The European Stroke Organisation Guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage provide recommendations for the appropriate management of blood pressure in various clinical acute stroke settings. In this narrative review, we provide specific updates on blood pressure management in ICH, blood pressure management in the setting of reperfusion therapies for ischaemic stroke, and the evidence for the use of induced hypertension in patients with acute ischaemic stroke in the light of the recent guidelines.

Abstract P883: A Survey of Acute Stroke Blood Pressure Management Practices in the Southeastern US

Background: IMPROVE Stroke Care is a regional implementation science study in the Southeastern US aimed at reducing acute stroke treatment times and improving outcomes through wide scale application of best practices. Optimal blood pressure in acute ischemic stroke (AIS) and acute intracerebral hemorrhage (ICH) remains controversial. Current guidelines lack specific targets for non-tPA treated AIS or ICH. We sought to evaluate current BP management processes for acute stroke within the 65 hospitals in the IMPROVE consortium. Methods: A 27-question survey was conducted using Qualtrics software. Topics covered existing protocols, guideline adherence, target BP in various settings, medication availability and use cases, and EMS practices. Simple proportions were calculated. Results: Overall survey completion rate was 71% (Hub 8/9 (89%) and Spoke 38/56 (68%)). The majority of participating sites (89%) have BP management protocols in place, as do their transport agencies (89%). Order sets are utilized for this in 87% of Emergency Departments and 83% of Intensive Care Units. Significant variation in practice was seen regarding goal BP in AIS patients who were not tPA candidates, with ‘provider discretion’, ‘unsure’ or ‘NA’ accounting for 63% of responses. Similarly, target BP prior to and following thrombectomy varied greatly. In tPA eligible AIS patients 76% (32/42) reported goal BP in line with the AHA guideline recommendation of <185/110mmHg; 21% (9/42) reported a goal <180/100mmHg. BP goals for ICH also vary widely, with systolic goals <150mmHg (46%) and <140mmHg (24%) the most common choices, with no difference in anticoagulated patients. The first-line drugs used in ED and EMS are labetalol (ED 83%/ EMS 35%), hydralazine (10%/26%), and nicardipine (8%/26%). In the ED, medications are obtained from a ‘cart or closet’ 62%, walked from pharmacy 27%, ‘tubed’ 17%, or ‘other’ 27%. Importantly, no participating sites indicated BP control as a common reason for stroke treatment delay. Conclusion: The survey demonstrates that many Southeastern US hospitals have BP management protocols in place that follow guidelines where available, and have tools to prevent treatment delays, yet no consensus exists on goal BP in thrombectomy, non-tPA treated AIS and ICH patients.

Impact of Arterial Blood Pressure Management in Acute Ischemic Stroke on Short Term Outcome and Prognosis

Background: Blood pressure (BP) is elevated in 75% or more of patients with acute stroke and is associated with poor outcomes. Whether to modulate BP in acute stroke has long been debated. With the loss of normal cerebral autoregulation, theoretical concerns are twofold: high BP can lead to cerebral edema, hematoma expansion or hemorrhagic transformation; and low BP can lead to increased cerebral infarction or perihematomal ischemia. Objective: To determine the impact of arterial blood pressure management in acute ischemic stroke on short term outcome and prognosis. Patients and methods: This study included 200 patients diagnosed with ischemic stroke and arrived to Emergency Hospital, Mansoura University over a year from June 2019 to June 2020. The cases were classified into 4 groups according to the systolic BP (SBP) of the cases; control group (SBP < 140 mmHg), group 2 (SBP 140-160 mmHg) group 3 (SBP 160-180 mmHg) and group 4 (SBP 180-200 mmHg). Results: The stroke score (follow up) according to blood pressure groups showed no statistically significant difference between the groups. Regarding the initial CT findings of the cases according to blood pressure groups, fourth group has more changes in CT brain, with a highly statistical significant difference observed between the groups. Conclusion: Elevated blood pressure in patients with stroke were associated with worse outcomes including ICU admission, mortality and duration of hospital admission. CT findings supported these findings as the percent of cases presented with initial infarction and cases who showed hemorrhagic transformation increased with elevation of BP.

Baseline characteristics of the 1149 patients recruited into the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) randomized controlled trial.

High blood pressure is common in acute stroke and associated with a worse functional outcome. Glyceryl trinitrate, a nitric oxide donor, lowers blood pressure in acute stroke and may improve outcome. Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) tested the feasibility of performing a UK multicenter ambulance-based stroke trial, and the safety and efficacy of glyceryl trinitrate when administered by paramedics before hospital admission. Paramedic-led ambulance-based multicenter prospective randomized single-blind blinded-endpoint parallel-group controlled trial of transdermal glyceryl trinitrate (given for four days) versus sham in patients with ultra-acute (<4 h) presumed stroke. Data are number (%), median (interquartile range) or mean (standard deviation). Recruitment ran from October 2015 to 31 May 2018. A total 1149 patients were recruited from eight UK ambulance services and taken to 54 acute hospitals. Baseline characteristics include: mean age 73 (15) years; female 555 (48%); median time from stroke to randomization 70 (45, 115) min; face-arm-speech scale score 2.6 (0.5); and blood pressure 162 (25)/92 (18) mmHg. The final diagnosis was ischemic stroke 52%, hemorrhagic stroke 13%, Transient Ischemic Attack (TIA) 9%, and mimic 25%. The main trial results will be presented in quarter 4 2018. The results will also be included in updated Cochrane systematic reviews, and individual patient data meta-analyses of all relevant randomized controlled trials. It was feasible to perform a multicenter ambulance-based ultra-acute stroke trial in the UK and to treat with glyceryl trinitrate versus sham. The relatively unselected cohort of stroke patients is broadly representative of those admitted to hospital in the UK. ISRCTN26986053.

Blood Pressure in Acute Stroke: To Treat or Not to Treat: That Is Still the Question.

One of the oldest questions in acute stroke management, and perhaps the most challenging since it has yet to be solved after more than half a century of published research, is how to manage high blood pressure (BP). The problem might be summed up as follows: > To treat , or not to treat : that is the question: > > Whether ’tis nobler in the mind to suffer > > The slings and arrows of outrageous pressure , > > Or to take drugs against a sea of blood , > > And by opposing end them? To live : to walk ; > > —With apologies to Shakespeare , Hamlet Act III, Scene I To treat, or not to treat, high BP was debated >30 years ago in 1985,1–3 and yet there is no definitive answer here in 2018. Part of the debate is driven by opposing arguments based on epidemiology and pathophysiology and part by the failure of every large trial to provide a definitive answer. There is considerable evidence that high BP is associated independently with a poor outcome after ischemic stroke (IS) whether defined by early recurrence or death, or late death and dependency.4,5 Similarly, high BP is related to hematoma expansion6 and functional outcome after intracerebral hemorrhage (ICH).7 A straightforward conclusion of this epidemiological evidence is that high BP should be lowered. In contrast, pathophysiological concerns are based on the presence of dysfunctional cerebral autoregulation during acute stroke, and so lowering BP will reduce tissue perfusion, increase lesion size, and thereby worsen outcome.8 There are many causes of high BP in acute stroke, including prior hypertension, acute neuroendocrine stimulation (via the renin-angiotensin-aldosterone system [RAAS], sympathetic autonomic nervous, and corticotrophin-cortisol systems), the Cushing reflex (due to raised intracranial pressure), and stress associated with admission to hospital and …

Managing high blood pressure during acute ischemic stroke and intracerebral hemorrhage.

Blood pressure (BP) elevations above premorbid levels are observed in at least 60% of acute ischemic and hemorrhagic stroke patients, within the first 24 h of symptom onset. A number of potential causes have been hypothesized, and high BP may be associated with poor stroke outcome. This review discusses management strategies of high BP in acute stroke, in the context of current guidelines. Excessive BP elevation can impact acute stroke therapeutic strategies, particularly in modifying intervention safety and efficacy. Currently, guidance on BP management in acute ischemic stroke and intracerebral hemorrhage (ICH) exists in a limited number of specific clinical presentations, including spontaneous ICH and continuing versus stopping preexisting antihypertensive therapy. However, ongoing clinical trials will further investigate the safety and efficacy of urgent BP-lowering therapy for other indications. There are clear national and international guidelines on BP lowering for specific indications, as well as ongoing clinical trials aiming to address common clinical scenarios in which the evidence-base is lacking and uncertain. This is specifically in important stroke subgroups previously excluded from trials, patients requiring mechanical thrombectomy and nonvitamin K antagonist-associated ICH reversal.

Management of blood pressure in acute stroke: Comparison of current prescribing patterns with AHA/ASA guidelines in a Sub-Saharan African referral hospital

BackgroundHigh blood pressure (HBP) is common at acute phase of stroke. It may reflect untreated or uncontrolled hypertension before stroke, or it may relate to stress response. The present study was designed to compare current American Stroke Association (ASA) guidelines with actual prescribing patterns for management of HBP at the acute phase of stroke, in a tertiary care Hospital in Douala, Cameroon. MethodsThis cross-sectional study was conducted in the Cardiology and Neurology department of the Douala Laquintinie Hospital. Consenting patients with sign of stroke, confirmed by a brain CT-scan, who consented to participate in the study were recruited from March to July 2012. The use of antihypertensive medications (type, dose, routes of administration, BP recordings) in the first three days after admission was noted. ResultsOne hundred and eleven patients were recruited including 59 men (53.1%). The mean age of patients was 60.9±12.3years, 70 patients (63%) had ischemic stroke and 41 (37%) hemorrhagic. Sixty two (55.8%) patients had hypertension severe enough to warrant treatment upon arrival. There was an overtreatment rate of 46.9% and undertreatment rate of 9.7%. ConclusionThe ASA guidelines were broadly respected by practitioners for patients who required treatment, but those who do not need treatment were overtreated. These findings support the need for more research to improve treatment guidelines as well as patient management.

PP.29.33] ANTIHYPERTENSIVE TREATMENT AND OUTCOME IN PATIENTS WITH ACUTE STROKE FROM BULGARIAN IN-HOSPITAL POPULATION

Objective: High blood pressure (BP) is considered an independent poor prognostic factor in acute stroke, but treating hypertension in the acute phase of stroke is a controversial issue. The aim of the study was to analyze the antihypertensive treatment, BP dynamics and outcome in patients with hypertensive crisis (HC) and acute ischemic (IS) or hemorrhagic stroke (HS). Design and method: 108 randomly selected in-hospital acute stroke patients (54 men and 54 women - 70 persons with IS and 38 with HS, accompanied by HC at admission (systolic blood pressure /SBP/ >180 mm Hg and /or diastolic blood pressure (DBP) >120 mm Hg). Antihypertensive medication, BP dynamics, and cliniical status were analyzed. Results: Almost all patients received (venous and/or oral) antihypertensive therapy and BP was reduced in the course of treatment. Drugs from all antihypertensive classes were administered. The most common agents were clonidine and furosemide (parenterally or orally), enalapril, amlodipin and bisoprolol (per os). Most of the patients received combined antihypertensive therapy with more than 2 drugs. Mean number of oral agents was 2,21 (2,5 for IS and 1,76 for HS /p = 0,006/). Patients with HS received significantly more venous medication. BP reduction was more pronounced in the first 24 hours (about 25% drop); afterwards smoother. Persons with HS demonstrated significantly higher levels of BP than those with IS at admission and the first hours. Patients with clinical improvement were with significantly lower levels of BP at baseline, 12th hour, third day, and at dismission than those with deterioration. Higher values of BP in the patients who died in hospital (4 with IS and 14 with HS) than those dismissed (significant in the first hours in HS and at the 3rd and 4th day in IS) were observed. Conclusions: Persistent high BP in acute stroke might be associated with worse prognosis. Differences between IS and HS in BP dynamics exist. Overall patients with HS and more severe stroke tend to have higher BP levels and worse outcome (no improvement, deterioration or death). High BP in the acute phase of stroke should be reduced carefully especially in IS patients.

Efficacy of Nitric Oxide, With or Without Continuing Antihypertensive Treatment, for Management of High Blood Pressure in Acute Stroke. Results of the ENOS study

Efficacy of Nitric Oxide, With or Without Continuing Antihypertensive Treatment, for Management of High Blood Pressure in Acute Stroke. Results of the ENOS study

ACP Journal Club: glyceryl trinitrate did not improve functional outcome in patients with acute stroke and high BP.

Source Citation ENOS Trial Investigators. Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomised controlled trial. Lancet. 2015;385:617-28. 25465108

Interventions for Deliberately Altering Blood Pressure in Acute Stroke

Interventions for Deliberately Altering Blood Pressure in Acute Stroke

Interventions for deliberately altering blood pressure in acute stroke.

It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001 and 2008. To assess the clinical effectiveness of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke. We searched the Cochrane Stroke Group Trials Register (last searched in February 2014), the Cochrane Database of Systematic reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 2), MEDLINE (Ovid) (1966 to May 2014), EMBASE (Ovid) (1974 to May 2014), Science Citation Index (ISI, Web of Science, 1981 to May 2014) and the Stroke Trials Registry (searched May 2014). Randomised controlled trials of interventions that aimed to alter blood pressure compared with control in participants within one week of acute ischaemic or haemorrhagic stroke. Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data. The review authors cross-checked data and resolved discrepancies by discussion to reach consensus. We obtained published and unpublished data where available. We included 26 trials involving 17,011 participants (8497 participants were assigned active therapy and 8514 participants received placebo/control). Not all trials contributed to each outcome. Most data came from trials that had a wide time window for recruitment; four trials gave treatment within six hours and one trial within eight hours. The trials tested alpha-2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide-like diuretics, and target-driven blood pressure lowering. One trial tested phenylephrine.At 24 hours after randomisation oral ACEIs reduced systolic blood pressure (SBP, mean difference (MD) -8 mmHg, 95% confidence interval (CI) -17 to 1) and diastolic blood pressure (DBP, MD -3 mmHg, 95% CI -9 to 2), sublingual ACEIs reduced SBP (MD -12.00 mm Hg, 95% CI -26 to 2) and DBP (MD -2, 95%CI -10 to 6), oral ARA reduced SBP (MD -1 mm Hg, 95% CI -3 to 2) and DBP (MD -1 mm Hg, 95% CI -3 to 1), oral beta blockers reduced SBP (MD -14 mm Hg; 95% CI -27 to -1) and DBP (MD -1 mm Hg, 95% CI -9 to 7), intravenous (iv) beta blockers reduced SBP (MD -5 mm Hg, 95% CI -18 to 8) and DBP (-5 mm Hg, 95% CI -13 to 3), oral CCBs reduced SBP (MD -13 mmHg, 95% CI -43 to 17) and DBP (MD -6 mmHg, 95% CI -14 to 2), iv CCBs reduced SBP (MD -32 mmHg, 95% CI -65 to 1) and DBP (MD -13, 95% CI -31 to 6), NO donors reduced SBP (MD -12 mmHg, 95% CI -19 to -5) and DBP (MD -3, 95% CI -4 to -2) while phenylephrine, non-significantly increased SBP (MD 21 mmHg, 95% CI -13 to 55) and DBP (MD 1 mmHg, 95% CI -15 to 16).Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05), stroke type (OR 0.98, 95% CI 0.92 to 1.05) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05). Treatment within six hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99) but not death (OR 0.70, 95% CI 0.38 to 1.26) at the end of the trial. Although death or dependency did not differ between people who continued pre-stroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24), disability scores at the end of the trial were worse in participants randomised to continue treatment (Barthel Index, MD -3.2, 95% CI -5.8, -0.6). There is insufficient evidence that lowering blood pressure during the acute phase of stroke improves functional outcome. It is reasonable to withhold blood pressure-lowering drugs until patients are medically and neurologically stable, and have suitable oral or enteral access, after which drugs can than be reintroduced. In people with acute stroke, CCBs, ACEI, ARA, beta blockers and NO donors each lower blood pressure while phenylephrine probably increases blood pressure. Further trials are needed to identify which people are most likely to benefit from early treatment, in particular whether treatment started very early is beneficial.

Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomised controlled trial

SummaryBackgroundHigh blood pressure is associated with poor outcome after stroke. Whether blood pressure should be lowered early after stroke, and whether to continue or temporarily withdraw existing antihypertensive drugs, is not known. We assessed outcomes after stroke in patients given drugs to lower their blood pressure.MethodsIn our multicentre, partial-factorial trial, we randomly assigned patients admitted to hospital with an acute ischaemic or haemorrhagic stroke and raised systolic blood pressure (systolic 140–220 mm Hg) to 7 days of transdermal glyceryl trinitrate (5 mg per day), started within 48 h of stroke onset, or to no glyceryl trinitrate (control group). A subset of patients who were taking antihypertensive drugs before their stroke were also randomly assigned to continue or stop taking these drugs. The primary outcome was function, assessed with the modified Rankin Scale at 90 days by observers masked to treatment assignment. This study is registered, number ISRCTN99414122.FindingsBetween July 20, 2001, and Oct 14, 2013, we enrolled 4011 patients. Mean blood pressure was 167 (SD 19) mm Hg/90 (13) mm Hg at baseline (median 26 h [16–37] after stroke onset), and was significantly reduced on day 1 in 2000 patients allocated to glyceryl trinitrate compared with 2011 controls (difference −7·0 [95% CI −8·5 to −5·6] mm Hg/–3·5 [–4·4 to −2·6] mm Hg; both p<0·0001), and on day 7 in 1053 patients allocated to continue antihypertensive drugs compared with 1044 patients randomised to stop them (difference −9·5 [95% CI −11·8 to −7·2] mm Hg/–5·0 [–6·4 to −3·7] mm Hg; both p<0·0001). Functional outcome at day 90 did not differ in either treatment comparison—the adjusted common odds ratio (OR) for worse outcome with glyceryl trinitrate versus no glyceryl trinitrate was 1·01 (95% CI 0·91–1·13; p=0·83), and with continue versus stop antihypertensive drugs OR was 1·05 (0·90–1·22; p=0·55).InterpretationIn patients with acute stroke and high blood pressure, transdermal glyceryl trinitrate lowered blood pressure and had acceptable safety but did not improve functional outcome. We show no evidence to support continuing prestroke antihypertensive drugs in patients in the first few days after acute stroke.FundingUK Medical Research Council.

Blood pressure in acute stroke: which questions remain?

In ENOS, one of the largest randomised trials of blood pressure-lowering in acute stroke now published in The Lancet, Philip Bath and colleagues1 assessed whether blood pressure could be safely lowered with a daily glyceryl nitrate patch for 7 days after acute stroke, and whether antihypertensive drugs should be continued or withdrawn. Blood pressure is increased in about 70% of patients with acute stroke and often falls spontaneously over the next few days.2 The potential causes of this transient rise include disturbed cerebral autoregulation, damage or compression of brain regions that regulate blood pressure, neuroendocrine disturbance, and non-specific mechanisms such as headache, urine retention, infection, and psychological stress.

Blood pressure in acute stroke

Although great advances have been made in stroke medicine in the past two decades, some questions about treatment in the acute phase of stroke remain. One such question is how to manage blood pressure? Blood pressure is often increased in acute ischaemic and haemorrhagic stroke,1 and findings from epidemiological studies suggest that high blood pressure in the acute phase is associated with poor outcome.1 The results of three large randomised clinical trials on blood pressure lowering in acute stroke—the Chinese Antihypertensive Trial in Acute Ischaemic Stroke2, the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT-2),3 and the Scandinavian Candesartan Acute Stroke Trial4—suggest that treatment should differ according to the type of stroke.

Management of blood pressure in acute stroke

The importance of elevated or low arterial blood pressure (BP) early after stroke, and the need for pharmacological intervention to control BP, remains controversial. Debate surrounds if, when and how to intervene. This debate is informed by conflicting results from observational data and underpowered clinical trials and substantive outcome data are lacking. Accordingly, management decisions have largely been left up to the individual treating physician and guidelines are based on ‘good practice’ and theory rather than level 1, grade A evidence. Substantial progress has been made in recent years, particularly in the field of hemorrhagic stroke, where recently presented and soon to completed large-scale trials may finally give us a firm evidence base. For ischemic stroke, many important studies have informed our understanding of the basic pathophysiology, epidemiology, treatment and outcomes of BP management in acute stroke and, although not yet constituting a solid ‘evidence base’, are helping us from the ‘cognitive quick-sand’ of small studies and personal experiences.