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June 2009

Aggressive Blood Pressure Lowering in Acute Ischemic Stroke

Arch Neurol. 2009;66(6):804-805. doi:10.1001/archneurol.2009.120

This most interesting article by Martin-Schild et al1 raises what I believe is a crucial question, viz, what is the best, safest level of blood pressure (BP) to be sought in its reduction? That is, what degree of reduction will decrease the risk of hemorrhage while ensuring brain perfusion that is as adequate as possible? In this regard, I had introduced BP reduction (hypotensive therapy) for acute intracranial bleeding in 19562; the original 4 cases had included 3 with proven aneurysms, 1 of which also had a probable intracerebral hemorrhage. Subsequently to determine the best, safest degree of BP reduction, a titration method was developed based on carefully monitored, induced cerebrovascular insufficiency for cases of subarachnoid hemorrhage due to ruptured brain aneurysms—this problem was deemed the more urgent one owing to the possibility of devastating recurrent hemorrhage as opposed to the initial problem of intracerebral hemorrhage. I do not know of any indisputable guidelines regarding BP reduction for the latter problem. (Carefully monitored BP reduction for ruptured brain aneurysms has been found safe and very effective both short-term2-4 and in long-term follow-up [to 51 years].5-7) Consequently, because Martin-Schild and colleagues are appropriately concerned about the risk of inducing intracerebral hemorrhage or other adverse events, what criteria do they use for determining the best, safest BP range to be reached in the reduction and what convincing evidence is available to support such a decision?

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