In the hyperacute phase of ischemic stroke, what is the recommended approach to blood pressure management?

• A. Aggressively lower BP to below 140/90 immediately
• B. Do not lower BP unless SBP ≥ 220 or DBP ≥ 120
• C. Lower BP to exactly 180/105
• D. Delay any BP assessment until imaging

Answer: (B)

In the hyperacute phase of ischemic stroke, preserving perfusion to the still-viable brain tissue is crucial because the penumbra can recover if blood flow is maintained. The brain’s autoregulation is impaired after an ischemic event, so lowering blood pressure too much could cut off blood supply to this at-risk area and worsen the stroke. Therefore, the best approach is to avoid lowering blood pressure unless it becomes markedly elevated, at which point a cautious, gradual reduction is considered to reduce the risk of hemorrhagic transformation or edema without sacrificing cerebral perfusion. This principle keeps perfusion to salvageable tissue while only intervening when pressure is dangerously high.