Blood Pressure Management in Patients With Acute Ischemic Stroke

Abstract

A 68-year-old right-hand-dominant man was brought to the hospital because of a speech disturbance and right arm and leg weakness. He awoke with these deficits and was last known to be symptom-free when retiring to bed the previous evening 8 hours earlier. His past medical history was notable for coronary heart disease, the patient having underwent coronary artery bypass surgery 7 years previously for unstable angina, but he had no known history of myocardial infarction. He also had hypertension and hyperlipidemia, and smoked 1 pack of cigarettes daily for more than 40 years. He had no history of calf claudication. His hypertension was being treated with a diuretic and ␤-adrenergic receptor blocker. He was also prescribed 325 mg of aspirin daily and an HMG CoA-reductase inhibitor (statin); however, his wife remarked that he often forgot to take his medications. His last total cholesterol was 240 mg/dL, with LDL cholesterol of 130 mg/dL. He had a strong family history of coronary heart disease after the age of 50. He had no known drug allergies. Physical ExaminationThe patient's blood pressure was 195/100 mm Hg in both arms, with a regular pulse of 90 bpm. His weight was 225 lb (body mass index: 31.4 kg/m 2 ). His lungs were clear to auscultation. Cardiac examination showed a laterally displaced point of maximum impulse with an S 4 gallop and a soft nonradiating systolic murmur at the base. His abdomen was obese without organomegaly and no abdominal bruits were detected. He had no rashes and no joint deformities. The left superficial temporal artery pulse was stronger than the right. There were soft bilateral anterior cervical bruits, left louder than right, but no supraclavicular bruits. There were bilateral femoral bruits. Radial pulses were 2 ϩ and symmetric. Dorsalis pedis and posterior tibial pulses were 1 ϩ . There was no pretibial or ankle edema. Neurological ExaminationThe patient was alert. He spoke haltingly and made frequent paraphasic errors, using inappropriate words and occasional neologisms. He was able to follow simple verbal commands but had difficulty with repetitions. Further cognitive evaluation could not be performed because of the language disturbance. Cranial nerve examination revealed a right homonymous visual field deficit to threat. Funduscopic examination disclosed arteriolar narrowing with arteriolar-venous nicking, but no hemorrhages. There were no Hollenhorst plaques. There was a left gaze preference with otherwise full extraocular movements and no nystagmus. Pupillary light reflexes were normal. The right corneal response was diminished and there was a mild right lower facial paresis. His gag response was absent and his tongue deviated to the right. Motor examination revealed normal bulk with diminished tone in his right arm. He had 3/5 proximal and 2/5 distal strength in the right arm, 4/5 strength in the right leg, and full strength in his left arm and leg. He had a coordination deficit consistent with the weakness in his right arm and leg and normal coordination on the left. Senso...

Guidelines for the Early Management of Adults With Ischemic Stroke

“…242,246 Conversely, aggressive treatment of blood pressure may lead to neurological worsening by reducing perfusion pressure to ischemic areas of the brain. 242,247,248 In a majority of patients, a decline in blood pressure occurs within the first hours after stroke even without any specific medical treatment. 241 The blood pressure often falls spontaneously when the patient is moved to a quiet room, the patient is allowed to rest, the bladder is emptied, or the pain is controlled.…”

Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient

“…151,152 There is evidence, however, that rapid lowering of blood pressure may induce worsening of neurological symptoms by inducing lowered perfusion pressures to the area of ischemia. 149,153,154 Arterial hypotension is rare in the AIS patient but may be associated with volume depletion or decreased cardiac output related to arrhythmias or myocardial ischemia. Patients with hypotension require evaluation with advanced neurological nursing assessment and telemetry monitoring.…”

Mild Induced Hypertension Improves Blood Flow and Oxygen Metabolism in Transient Focal Cerebral Ischemia

“…It is generally recommended that mild to moderate spontaneous elevations in MAP should not be treated during acute stroke. 11 On the contrary, pharmacologically induced hypertension seems to improve tissue and functional outcome in experimental focal ischemia in rats, 1,[12][13][14][15] rabbits, 2 dogs, 16 and monkeys. 4,17 Several case reports and small patient series also suggest feasibility and efficacy in human acute ischemic stroke 18 -31 ; however, data from larger prospective, randomized trials are not yet available.…”