2025 update to European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage

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 reduction to < 140 mmHg in patients with small-to-moderate haematomas to limit haematoma expansion. Overall, the updated recommendations reaffirm the core principles of current clinical practice while providing more nuanced guidance for specific scenarios. However, the quality of evidence remains moderate to very low, limited by a lack of high-quality RCTs, methodological issues, inconsistent results and study heterogeneity. Consequently, most recommendations are weak and supported by expert consensus. These guidelines provide specific recommendations on BP thresholds and management strategies tailored to distinct acute stroke subgroups. They also highlight the ongoing uncertainty and emphasise the need for future RCTs to define optimal BP targets, timing, treatment strategies and ideal antihypertensive agents across different clinical contexts.