The problem of a patient presenting to an emergency room with severe hypertension and a central nervous system (CNS) deficit is a common, dangerous, and vexing one. The received wisdom for many years has been: "in a patient with stroke, one must not treat the blood pressure, for fear of making the stroke worse." Indeed, examples abound of the disastrous consequences of aggressive treatment of severe hypertension. Even in patients presenting without any initial focal neurologic deficit, abrupt lowering of blood pressure may produce collapse, seizures, focal CNS deficits, and optic neuropathy, which have been assumed to be ischemic.1-3
Presumably, advocates of the hands-off policy believe that abrupt lowering of blood pressure is dangerous because sudden reduction of cerebral perfusion pressure may render ischemic those parts of the brain whose blood supply is borderline because of arterial disease (eg, carotid occlusion) or areas of brain in which blood supply
Spence JD, Del Maestro RF. Hypertension in Acute Ischemic Strokes: Treat. Arch Neurol. 1985;42(10):1000–1002. doi:10.1001/archneur.1985.04060090082019
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