Neurocritical Care

, Volume 1, Issue 3, pp 287–299 | Cite as

Optimizing blood pressure in neurological emergencies

  • Jack C. Rose
  • Stephan A. Mayer


Excessive hypertension can challenge the brain’s capacity to autoregulate cerebral blood flow, and can aggravate increased intracranial pressure (ICP) and cerebral edema. Hypotension may worsen ischemic damage in marginally perfused tissue, and in some cases can trigger cerebral vasodilation and ICP plateau waves. There is a lack of high-quality data regarding optimal BP management in these conditions.

Existing guidelines for target BP levels are based largely on class III evidence. Class I data only exist for enteral candesartan and nimodipine use in acute ischemic stroke and aneurismal subarachnoid hemorrhage (SAH), respectively, and for parenteral magnesium use in eclampsia. Class II data exist for reducing BP to <180/ 105 mmHg in patients with ischemic stroke who are treated with intravenous tissue plasminogen activator, for elevating systolic BP to 180–220 mmHg in SAH patients with symptomatic vasospasm, and for maintaining cerebral perfusion pressure (CPP)>60 mmHg in traumatic brain injury. Short-acting continuous-infusion agents with a reliable dose—response relationship and favorable safety profile are desirable. To reduce BP, labetalol, esmolol, and nicardipine best meet these criteria. Sodium nitroprusside should be avoided in most neurological emergencies because of its tendency to raise ICP and cause toxicity with prolonged infusion. To elevate BP, the preferred agents are phenylephrine, dopamine, and norepinephrine.

Key Words

Blood pressure neurological emergencies autoregulation cerebral perfusion pressure 


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  1. 1.
    Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension 2003;42:1206–1252.PubMedCrossRefGoogle Scholar
  2. 2.
    Zampaglione B, Pascale C, Marchisto M, Cavallo-Perin P. Hypertensive urgencies and emergencies: prevalence and clinical presentation. Hypertension 1996;27:144–147.PubMedGoogle Scholar
  3. 3.
    Chalmers J. Volhard lecture: brain, blood pressure and stroke. J Hypertens 1998;16:1849–1858.PubMedCrossRefGoogle Scholar
  4. 4.
    Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000;356:411–417.PubMedCrossRefGoogle Scholar
  5. 5.
    Powers WJ. Acute hypertension after stroke: the scientific basis for treatment decisions. Neurology 1993;43:461–467.PubMedGoogle Scholar
  6. 6.
    Baron JC. Perfusion thresholds in human cerebral ischemia: historical perspective and therapeutic implications. Cerebrovasc Dis 2001;11:2–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Nates JL, Niggemeyer LE, Anderson MB, Tuxen DV. Cerebral perfusion pressure monitoring alert! [letter]. Critical Care Med 1997;25:895–896.CrossRefGoogle Scholar
  8. 8.
    Darby JM, Yonas H, Marks EC, Durham S, Snyder RW, Nemoto EM. Acute cerebral blood flow response to dopamine-induced hypertension after subarachnoid hemorrhage. J Neurosurg 1994,80:857–864.PubMedGoogle Scholar
  9. 9.
    Varon J, Marik PE. The diagnosis and management of hypertensive crises. Chest 2000;118: 214–227.PubMedCrossRefGoogle Scholar
  10. 10.
    Cottrell JE, Patel K, Turndorf H, Ransohoff J. Intracranial pressure changes induced by sodium nitroprusside in patients with intracranial mass lesions. J Neurosurg 1978;48:329–331.PubMedGoogle Scholar
  11. 11.
    Weiss MH, Spence J, Apuzzo ML, Heiden JS, McComb JG, Kurze T. Influence of nitroprusside on cerebral pressure autoregulation. Neurosur-gery 1979;4:56–59.CrossRefGoogle Scholar
  12. 12.
    Turner JM, Powell D, Gibson RM, McDowall DG. Intracarnial pressure changes in neurosurgical patients during hypotension induced with sodium nitrprusside or trimethaphan. Br J Anesthesia 1977;49:419–425.CrossRefGoogle Scholar
  13. 13.
    Levy JH. Treatment of perioperative hypertension. Anesthesiol Clin North Am 1999;17:567–579.CrossRefGoogle Scholar
  14. 14.
    Oparil S, Aronson S, Deeb GM, et al. Fenoldopam: a new parenteral antihypertensive: consensus roundtable on the management of perioperative hypertension and hypertensive crises. Am J Hypertens 1999;12:653–664.PubMedCrossRefGoogle Scholar
  15. 15.
    Donnan GA, Davis SM, Thrift A. The role of blood pressure lowering before and after stroke. Curr Opin Neurol 2003;16:81–86.PubMedCrossRefGoogle Scholar
  16. 16.
    Yatsu FM, Zivin J. Hypertension in acute ischemic strokes: not to treat. Arch Neurol 1985;42: 999–1000.PubMedGoogle Scholar
  17. 17.
    Spence JD. Hypertension in acute ischemic strokes: treat. Arch Neurol 1985;42:1000–1002.PubMedGoogle Scholar
  18. 18.
    International Society of Hypertension. Statement on the management of blood pressure in acute stroke. J Hypertens 2003;21:665–672.CrossRefGoogle Scholar
  19. 19.
    Johnston KC, Mayer SA. Blood pressure reduction in ischemic stroke: a two-edged sword? Neurology 2003;61:1030–1031.PubMedGoogle Scholar
  20. 20.
    Boysen G. Persisting dilemma: to treat or not to treat blood pressure in acute ischemic stroke. Stroke 2004;35:526–527.PubMedCrossRefGoogle Scholar
  21. 21.
    Adams HP, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the stroke council of the American Stroke Association. Stroke 2003;34:1056–1083.PubMedCrossRefGoogle Scholar
  22. 22.
    The European Stroke Initiative Executive Committee and the EUSI Writing Committee. European Stroke Initiative recommendations for stroke management—update 2003. Cerebrovasc Dis 2003;16:311–337.CrossRefGoogle Scholar
  23. 23.
    Wallace JD, Levy LL. Blood pressure after stroke. JAMA 1981;246:2177–2180.PubMedCrossRefGoogle Scholar
  24. 24.
    Britton M, Carlsson A, de Faire U. Blood pressure course in patients with acute stroke and matched controls. Stroke 1986;17:861–864.PubMedGoogle Scholar
  25. 25.
    Novak V, Chowdhary A, Farrar B, et al. Altered cerebral vasoregulation in hypertension and stroke. Neurology 2003;60:1657–1663.PubMedGoogle Scholar
  26. 26.
    Lanvin P. Management of hypertension in patients with acute stroke. Arch Intern Med 1986;146:66–68.CrossRefGoogle Scholar
  27. 27.
    Ahmed N, Nasman P, Wahlgren NG. Effect of intravenous nimodipine on blood pressure and outcome after acute stroke. Stroke 2000;31: 1250–1255.PubMedGoogle Scholar
  28. 28.
    Wahlgren NG, MacMahon DG, DeKeyser J, et al. The Intravenous Nimodipine West European Trial (INWEST) of nimodipine in the treatment of acute ischemic stroke. Cerebrovasc Dis 1994;4:204–210.Google Scholar
  29. 29.
    Wise G, Sutter R, Burkholder J. The treatment of brain ischemia with vasopressor drugs. Stroke 1972;3:135–140.PubMedGoogle Scholar
  30. 30.
    Rordorf G, Cramer SC, Efird JT, Schwamm LH, Buonanno F, Koroshetz WJ. Pharmacological elevation of blood pressure in acute stroke. Stroke 1997;28:2133–2138.PubMedGoogle Scholar
  31. 31.
    Hillis AE, Ulatowski JA, Barker PB, et al. A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and subacute stroke. Cerebrovasc Dis 2003;16:236–246.PubMedCrossRefGoogle Scholar
  32. 32.
    Carlberg B, Asplund K, Hagg E. The prognostic value of admission blood pressure in patients with acute stroke. Stroke 1993;24:1372–1375.PubMedGoogle Scholar
  33. 33.
    Ahmed N, Wahlgren G. High initial blood pressure after acute stroke is associated with poor functional outcome. J Intern Med 2001;249: 467–473.PubMedCrossRefGoogle Scholar
  34. 34.
    Aslanyan S, Fazekas F, Weir CJ, Horner S, Lees KR. Effect of blood pressure during the acute period of ischemic stroke on stroke outcome: a tertiary analysis of the GAIN international trial. Stroke 2003;34:2420–2425.PubMedCrossRefGoogle Scholar
  35. 35.
    Fiorelli M, Alperovitch A, Argentino C, et al. Prediction of long-term outcome in the early hours following acute ischemic stroke. Arch Neurol 1995;52:250–255.PubMedGoogle Scholar
  36. 36.
    Semplicini A, Maresca A, Boscolo G, et al. Hypertension in acute ischemic stroke: a compensatory mechanism or an additional damaging factor? Arch Intern Med 2003;163:211–216PubMedCrossRefGoogle Scholar
  37. 37.
    Jorgensen H, Nakayama H, Raaschou H, Olsen TS. Effect of blood pressure and diabetes on stroke in progression. Lancet 1994;334:156–159.CrossRefGoogle Scholar
  38. 38.
    Leonardi-Bee J, Bath PMW, Phillips SJ, Sandercock PAG. Blood pressure and clinical outcomes in the international stroke trial. Stroke 2002;33: 1315–1320.PubMedCrossRefGoogle Scholar
  39. 39.
    Vemmos KN, Tsivgoulis G, Spengos K, et al. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J Int Med 2004;255:257–265.CrossRefGoogle Scholar
  40. 40.
    Chamorro A, Vila N, Ascano C, Elices E, Schonewille W, Blanc R. Blood pressure and functional recovery in acute ischemic stroke. Stroke 1998;29:1850–1853.PubMedGoogle Scholar
  41. 41.
    Christensen H, Meden P, Overgaard K, Boysen G. The course of blood pressure in acute stroke is related to the severity of neurological deficits. Acta Neurol Scand 2002;106:142–147.PubMedCrossRefGoogle Scholar
  42. 42.
    Oliveira-Filho J, Silva SCS, Trabuco CC, Pedreira BB, Sousa EU, Bacellar A. Detrimental effect of blood pressure reduction in the first 24 hours of acute stroke onset. Neurology 2003;61:1047–1051.PubMedGoogle Scholar
  43. 43.
    International Society of Hypertension Writing Group. International Society of Hypertension (ISH): statement on the management of blood pressure in acute stroke. J Hypertens 2003;21: 665–672.CrossRefGoogle Scholar
  44. 44.
    Schrader J, Luders S, Kulschewski A, et al. The ACCESS study: evaluation of acute candesartan cilexetil therapy in stroke survivors. Stroke 2003;34:1699–1703.PubMedCrossRefGoogle Scholar
  45. 45.
    Krieger DW, Demchuk AM, Kasner SE, Jauss M, Hantson L. Early clinical and radiological predictors of fatal brain swelling in ischemic stroke. Stroke 1999;30:287–292.PubMedGoogle Scholar
  46. 46.
    Kasner SE, Demchuk AM, Berrouschot J, et al. Predictors of fatal brain edema in massive hemispheric ischemic stroke. Stroke 2001;32: 2117–2123.PubMedGoogle Scholar
  47. 47.
    Levy DE, Brott TG, Haley C, et al. Factors related to intracranial hematoma formation in patients receiving tissue-type plasminogen activator for acute ischemic stroke. Stroke 1994;25:291–297.PubMedGoogle Scholar
  48. 48.
    Brott T, Lu M, Kothari R, et al. Hypertension and its treatment in the NINDS rt-PA stroke trial. Stroke 1998;29:1504–1509.PubMedGoogle Scholar
  49. 49.
    Gilligan AK, Markus R, Read S, et al. Baseline blood pressure but not early computed tomography changes predicts major hemorrhage after streptokinase in acute ischemic stroke. Stroke 2002;33:2236–2242.PubMedCrossRefGoogle Scholar
  50. 50.
    Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke: the PROACT II study: a randomized controlled trial. JAMA 1999;282:2003–2011.PubMedCrossRefGoogle Scholar
  51. 51.
    Kase CS, Furlan AJ, Wechsler L, et al. Cerebral hemorrhage after intra-arterial thrombolysis for ischemic stroke: the PROACT II trial. Neurology 2001;57:1603–1610.PubMedGoogle Scholar
  52. 52.
    Wechsler LR, Roberts R, Furlan AJ, et al. Factors influencing outcome and treatment effect in PROACT II. Stroke 2003;34:1224–1229.PubMedCrossRefGoogle Scholar
  53. 53.
    Tirschwell DL, Coplin WM, Becker KJ, et al. Intra-arterial urokinase for acute ischemic stroke: factors associated with complications. Neurology 2001;57:1100–1103.PubMedGoogle Scholar
  54. 54.
    Kidwell CS, Saver JL, Carneado J, et al. Predictors of hemorrhagic transformation in patients receiving intra-arterial thrombolysis. Stroke 2002;33: 717–24.PubMedCrossRefGoogle Scholar
  55. 55.
    Mayberg MR, Batjer HH, Dacey R, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the stroke council of the American Heart Association. Stroke 1994;25:2315–2328.PubMedGoogle Scholar
  56. 56.
    Naidech AM, Janjua N, Kowalski RG, Kreiter KT, Ostapkovich ND, Fitzsimmons B-F, Parra A, Commichau C, Connolly ES, Mayer SA: Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol 2004 (in press).Google Scholar
  57. 57.
    Ohkuma H, Tsurutani H, Suzuki S. Incidence and significance of early aneursymal rebleeding before neurosurgical or neurological management. Stroke 2001;32:1176–1180.PubMedGoogle Scholar
  58. 58.
    Claassen J, Vu A, Kreiter KT, Du EY, Connolly ES, Fitzsimmons B-F, Mayer SA: Impact of acute physiologic derangements on outcome after subarachnoid hemorrhage. Crit Care Med 2004;32:832–838.PubMedCrossRefGoogle Scholar
  59. 59.
    Wijdicks, EFM. Aneurysmal subarachnoid hemorrhage, in The Clinical Practice of Critical Care Neurology, 2nd ed., Oxford University Press: Oxford, UK, 2003, pp. 185–220.Google Scholar
  60. 60.
    Treggiari MM, Walder B, Suter PM, Romand J-A. Systematic review of the prevention of delayed ischemic neurological deficits with hypertension, hypervolemia, and hemodilution therapy following subarachnoid hemorrhage. J Neurosurg 2003;98:978–984.PubMedGoogle Scholar
  61. 61.
    Miller JA, Dacey RG, Diringer MN. Safety of hypertensive hypervolemic therapy with phenylephrine in the treatment of delayed ischemic deficits after subarachnoid hemorrhage. Stroke 1995;26:2260–2266.PubMedGoogle Scholar
  62. 62.
    Bernardini GL, Mayer SA, Kossoff SB, Hacein-Bey L, Solomon RA, Pile-Spellman J. Anticoag-ulation and induced hypertension after endovascular treatment for ruptured intracranial aneurysms. Crit Care Med 2001;29:641–644.PubMedCrossRefGoogle Scholar
  63. 63.
    Levy ML, Rabb CH, Zelman V, Giannotta SL. Cardiac performance enhancement from dobutamine in patients refractory to hypervolemic therapy for cerebral vasospasm. J Neurosurg 1993,79:494–499.PubMedGoogle Scholar
  64. 64.
    Willmot M, Leonardi-Bee J, Bath PMW. High blood pressure in acute stroke and subsequent outcome: a systematic review. Hypertension 2004;43:18–24.PubMedCrossRefGoogle Scholar
  65. 65.
    Terayama Y, Tanahashi N, Fukuchi Y, Gotoh F. Prognostic value of admission blood pressure in patients with intracerebral hemorrhage. Stroke 1997;28:1185–1188.PubMedGoogle Scholar
  66. 66.
    Fogelholm R, Avikainen S, Murros K. Prognostic value and determinants of first-day mean arterial pressure in spontaneous supratentorial intracerebral hemorrhage. Stroke 1997;28: 1396–1400.PubMedGoogle Scholar
  67. 67.
    Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001;32:891–897.PubMedGoogle Scholar
  68. 68.
    Qureshi AI, Bliwise DL, Bliwise NG, Akbar MS, Uzen G, Frankel MR. Rate of 24-hour blood pressure decline and mortality after spontaneous intracerebral hemorrhage: a retrospective analysis with a random effects regression model. Crit Care Med 1999;27:480–485.PubMedCrossRefGoogle Scholar
  69. 69.
    Mayer SA. Ultra-early hemostatic therapy for intracerebral hemorrhage. Stroke 2003;34: 224–229.PubMedCrossRefGoogle Scholar
  70. 70.
    Becker KJ, Baxter AB, Bybee HM, Tirschwell DL, Abouelsaad T, Cohen WA. Extravasation of radiographic contrast is an independent predictor of death in primary intracerebral hemorrhage. Stroke 1999;30:2025–2032.PubMedGoogle Scholar
  71. 71.
    Broderick JP, Adams HP, Barsan W, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a special writing group of the stroke council, American Heart Association. Stroke 1999;30:905–915.PubMedGoogle Scholar
  72. 72.
    Zazulia AR, Diringer MN, Videen TO, et al. Hypoperfusion without ischemia surrounding acute intracerebral hemorrhage. J Cereb Blood Flow Metab 2001;21:804–810.PubMedCrossRefGoogle Scholar
  73. 73.
    Schellinger PD, Fiebach JB, Hoffmann K. Stroke MRI in intracerebral hemorrhage: is there a perihemorrhagic penumbra? Stroke 2003;34: 1674–1679.PubMedCrossRefGoogle Scholar
  74. 74.
    Powers WJ, Zazulia AR, Videen TO, et al. Autoregulation of cerebral blood flow surrounding acute (6 to 22 hours) intracerebral hemorrhage. Neurology 2001;57:18–24.PubMedCrossRefGoogle Scholar
  75. 75.
    Bullock RM, Chesnut R, Clifton GL, et al. Management and prognosis of severe traumatic brain injury, part 1: Guidelines for the management of severe traumatic brain injury. J Neurotrauma 2000;17:451–553.Google Scholar
  76. 76.
    Marion DW, Darby J, Yonas H. Acute regional cerebral flow changes caused by severe head injuries. J Neurosurg 1991;74:407–414.PubMedGoogle Scholar
  77. 77.
    McLaughlin MR, Marion DW. Cerebral blood flow and vasoresponsivity within and around cerebral contusions. J Neurosurg 1996;85: 871–876.PubMedGoogle Scholar
  78. 78.
    Verweij BH, Muizelaar JP, Vinas FC, et al. Impaired cerebral mitochondrial function after traumatic brain injury in humans. J Neurosurg 2000;93:815–820.PubMedCrossRefGoogle Scholar
  79. 79.
    Martin NA, Patwardhan RV, Alexander MJ, et al. Characterization of cerebral hemodynamic phases after severe head trauma: hypoperfusion, hyperemia, and vasospasm. J Neurosurg 1997;87:9–19.PubMedGoogle Scholar
  80. 80.
    Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg 1995;83:949–962.PubMedCrossRefGoogle Scholar
  81. 81.
    Robertson CS, Valadka AB, Hannay HJ, et al. Prevention of secondary ischemic insults after severe head injury. Crit Care Med 1999;27: 2086–2095.PubMedCrossRefGoogle Scholar
  82. 82.
    Steiner LA, Johnston AJ, Csonyka M, et al. Direct comparison of cerebrovascular effects of noreprinephrine and dopamine in head-injured patients. Crit Care Med. 2004;32:1049–1054.PubMedCrossRefGoogle Scholar
  83. 83.
    Eker C, Asgeirsson B, Grande PO, Schalen W, Nordstrom CH. Improved outcome after severe head injury with a new therapy based on principles for brain volume regulation and preserved microcirculation. Crit Care Med 1998;26:1881–1886.PubMedGoogle Scholar
  84. 84.
    Nordstrom CH, Reinstrup P, Xu W, Gardenfors A, Ungerstedt U. Assessment of the lower limit for cerebral perfusion pressure in severe head injuries by bedside monitoring of regional energy metabolism. Anesthesiology 2003;98:805–807CrossRefGoogle Scholar
  85. 85.
    Steiner LA, Czosnyka M, Piechnik SK, et al. Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med 2002;30: 733–738.PubMedCrossRefGoogle Scholar
  86. 86.
    Stevens RD, Bhardwai A, Kirsch JR, Mirski MA. Critical care and perioperative management in traumatic spinal cord injury. J Neurosurg Anesthesiol 2003;15:215–229.PubMedCrossRefGoogle Scholar
  87. 87.
    Anonymous. Blood pressure management after acute spinal cord injury. Neurosurgery 2002;50: S58–62.Google Scholar
  88. 88.
    Cheung AT. Weiss SJ. McGarvey ML. Stecker MM. Hogan MS. Escherich A. Bavaria JE. Interventions for reversing delayed-onset postoperative paraplegia after thoracic aortic reconstruction. Ann Thoracic Surg. 2002;74:413–419CrossRefGoogle Scholar
  89. 89.
    Ackerman LL, Traynelis VC. Treatment of delayed-onset neurological deficit after aortic surgery with lumbar cerebrospinal fluid drainage. Neurosurgery 2002;51:1414–1421.PubMedCrossRefGoogle Scholar
  90. 90.
    Teitelbaum JS. Management of blood pressure in acute neurological illnesses, in Neurological Therapeutics: Principles and Practice. (Noseworthy JH, ed.), Martin Dunitz: London, UK, 2003, pp. 1148–1160.Google Scholar
  91. 91.
    Sibai BM. Treatment of hypertension in pregnant women. New Engl J Med 1996;335:257–265.PubMedCrossRefGoogle Scholar
  92. 92.
    Lucas MJ, Leveno KJ, Cunningham FG. A comparison of phenytoin and magnesium sulfate for the prevention of eclampsia. New Engl J Med 1995;333;201–205.PubMedCrossRefGoogle Scholar
  93. 93.
    Carbonne B, Jannet P, Touboul L, Khelifati Y, Milliez J. Nicardipine treatment of hypertension during pregnancy. Obstet Gynecol 1993;81: 908–914.PubMedGoogle Scholar

Copyright information

© Humana Press Inc 2004

Authors and Affiliations

  1. 1.Department of NeurologyColumbia University College of Physicians and SurgeonsNew York
  2. 2.Department of NeurosurgeryColumbia University College of Physicians and SurgeonsNew York

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