What do we (not) know about the management of blood pressure in acute stroke?

Although it is indisputable that high blood pressure should be treated to prevent a first or a recurrent stroke, the management of high blood pressure in the first hours and days after stroke remains controversial. There is no high-quality evidence from randomized controlled trials to guide treatment in the 80% of patients who have elevated blood pressure during the first days after stroke. Theoretically, there are pros and cons for manipulating blood pressure after onset of stroke. Most treatment guidelines suggest leaving blood pressure untouched based on pathophysiologic principles. Post-hoc analyses from randomized trials, however, suggest that elevated blood pressure is associated with recurrent stroke and higher mortality, even after adjustment for potential confounders. On the other hand, preliminary studies have suggested that voluntarily increasing blood pressure might be beneficial in a selected subgroup of patients. In this overview, we present a summary of recent studies on this topic.