Launched on 6th of October 2026

Cardio.toolsby Mohamed Ghazy, MD CardiologyAin Shams University, Egypt · Cardiology Consultant, Saudi ArabiaScopus ID: 55257919100
Hypertensive emergencies

Acute neurological BP targets

Gives the blood pressure at which to start lowering and the target for the major acute neurological emergencies: acute ischaemic stroke without reperfusion (permissive hypertension up to 220/120), before and after IV thrombolysis (< 185/110, then < 180/105 for 24 h), before, during and after thrombectomy (≤ 185/110, then ≤ 180/105 without intensive lowering below 140), intracerebral haemorrhage (SBP ~140 kept within 130–150, never below 130) and aneurysmal subarachnoid haemorrhage before the aneurysm is secured (SBP < 160). ACC/AHA defers acute stroke BP to the AHA/ASA stroke guidelines, which are shown beside the ESC 2024 hypertensive emergency recommendations; where ESC is silent (thrombectomy, SAH) the European Stroke Organisation guidance is shown and labelled.

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Neurological emergency
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Acute BP target
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Acute neurological BP targets
Thresholds and targets revised against the AHA/ASA stroke guidelines, ESC 2024 and, where ESC is silent, the European Stroke Organisation (ESO)
ConditionUpper limit / thresholdActive treatment targetNotes & rationaleSource
Acute ischaemic stroke, no reperfusion therapy≥ 220/120 mmHgLower by ~15% (AHA/ASA: over the first 24 h; ESC: MAP within 1 h)Permissive hypertension protects perfusion of the penumbra. Below 220/120, do not start treatment in the first 48–72 h.AHA/ASA 2019 (IIb) · ESC 2024
Acute ischaemic stroke, IV thrombolysis (alteplase / tenecteplase)> 185/110 mmHg< 185/110 before the bolus; < 180/105 for 24 h afterReduces symptomatic intracranial haemorrhage after thrombolysis.AHA/ASA 2019 (I) · ESC 2024 · ESO 2021
Acute ischaemic stroke, endovascular thrombectomy (EVT)> 185/110 before; > 180/105 during and after≤ 185/110 before; ≤ 180/105 during and for 24 h afterIntensive lowering (SBP < 140) after successful recanalisation worsens outcomes and is not recommended.AHA/ASA 2019 (IIa) · ESO 2021 · ENCHANTED2/MT, OPTIMAL-BP
Acute intracerebral haemorrhage (ICH)SBP 150–220 mmHg (AHA); SBP > 180 or ≥ 220 (ESC)AHA: ~140, kept within 130–150. ESC: < 180 (130–180)Early, smooth lowering limits haematoma growth. SBP < 130 is potentially harmful (renal injury, no benefit).AHA/ASA 2022 (I; < 130 III) · ESC 2024 (IIa)
Aneurysmal subarachnoid haemorrhage (SAH)SBP > 160 mmHg (ESO: > 180)SBP < 160 until the aneurysm is secured; avoid hypotensionLimits rebleeding. No guideline sets a trial-based target; SBP < 160 is practice-based.AHA/ASA 2023 · NCS · ESO 2013
References
  1. Powers WJ, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines (AHA/ASA). Stroke 2019;50:e344-e418.
  2. Greenberg SM, et al. 2022 Guideline for the management of patients with spontaneous intracerebral hemorrhage (AHA/ASA). Stroke 2022;53:e282-e361.
  3. Hoh BL, et al. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage (AHA/ASA). Stroke 2023;54:e314-e370.
  4. McEvoy JW, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J 2024;45:3912-4018.
  5. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Circulation 2025.
  6. Sandset EC, et al. European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J 2021;6:XLVIII-LXXXIX.
  7. Steiner T, et al. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis 2013;35:93-112.
  8. Qureshi AI, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage (ATACH-2). N Engl J Med 2016;375:1033-1043.
  9. Yang P, et al. Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT). Lancet 2022;400:1585-1596.
  10. Nam HS, et al. Intensive vs conventional blood pressure lowering after endovascular thrombectomy in acute ischemic stroke: the OPTIMAL-BP randomized clinical trial. JAMA 2023;330:832-842.
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