2025 update to European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage
Abstract
Optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute ICH remains uncertain. In light of new data published since the previous ESO guidelines, this update provides revised, evidence-based recommendations across 8 key clinical questions to support BP management in acute stroke. The guidelines were developed using the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, including literature searches, systematic reviews and meta-analyses of relevant RCTs, assessment of evidence quality and formulation of specific recommendations. We advise against routine pre-hospital BP lowering in suspected stroke (moderate-certainty evidence). In AIS patients undergoing reperfusion therapy, we recommend maintaining BP < 185/110 mmHg before the bolus of intravenous thrombolysis and < 180/105 mmHg during and for 24 h after intravenous thrombolysis (low-certainty evidence) and/or mechanical thrombectomy (moderate-certainty evidence). We recommend against intensively lowering systolic BP < 140 mmHg in the first 24 h after successful mechanical thrombectomy (high-certainty evidence). Routine use of vasopressors to raise BP in AIS patients with neurological deterioration who are not treated with acute reperfusion therapies is discouraged (low-certainty evidence). In acute ICH, the net clinical benefit of intensive BP lowering remains uncertain; however, expert consensus supports early systolic BP…
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