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Stroke Coding Guide of the American Academy of Neurology

Table 1.
Algorithm for emergency treatment of blood pressure in patients with ischemic stroke.


  1. Blood pressure obtained by automatic sphygmomanometer should be correlated with a manual blood pressure cuff reading.
  1. If diastolic blood pressure > 140 mm Hg occurs on two readings 5 minutes apart, then start a continuous IV infusion of an antihypertensive agent such as sodium nitroprusside (0.5-1.0 mg/kg/min). Patients who fall into this category are not candidates for t-PA therapy even if other inclusion criteria are met.
  1. If systolic blood pressure is > 220 mm Hg or diastolic bloodpressure is 121-140 mm Hg or mean arterial blood pressure is > 130 mm Hg on tworeadings 20 minutes apart, then give an easily titratable antihypertensive medication suchas labetalol at 10 mg IV over 1-2 minutes. The labetalol dose may be repeated or doubledevery 10-20 minutes until a cumulative dose of 300 mg has been administered via thismini-bolus technique. After the initial dosing schedule, labetalol doses may beadministered every 6-8 hours as needed. Labetalol is usually avoided in patients withasthma, cardiac failure, or severe cardiac conduction abnormalities. Enalapril (1.25 mgover 5 minutes and repeated every 6 hours or as needed) is an acceptable alternative, particularly in patients with congestive heart failure. Consider starting with 0.625 mgover 5 minutes in the elderly. IV esmolol or small patches of nitropaste are otheroptions. Patients who require more than two doses of labetalol or other antihypertensiveagents to decrease blood pressure to < 185 mm Hg systolic or 110 mm Hg diastolic aregenerally not candidates for thrombolytic therapy even if other criteria are met.
  1. If systolic blood pressure is 185-220 mm Hg or diastolic bloodpressure is 105-120 mm Hg, emergency therapy should be deferred in the absence of leftventricular failure, aortic dissection, or acute myocardial ischemia. Patients who arepotential candidates for t-PA therapy, but who have persistent elevations in systolicblood pressure of > 185 mm Hg or diastolic pressure of > 110 mm Hg may be treatedwith small doses of IV antihpertensive medication to maintain the blood pressure justbelow these limits. However, more than two doses of an antihypertensive agent to lower theblood pressure below these limits is a relative contraindication for thrombolytic therapyand should be discouraged.
  1. If blood pressure is lowered by antihpertensive agents in the setting of acute stroke, serial neurological examinations should be performed to look for signs of deterioration such as increasing weakness or reduced level of consciousness.
  1. In acute stroke patients with systolic blood pressure < 185 mm Hg or diastolic blood pressure < 105 mm Hg, antihypertensive therapy is usually not indicated.
  1. Although there are no data to support a threshold for treatment of hypotension in stroke patients, we recommend treatment for signs of dehydration, blood pressure that is substantially below the expected level for a given patient (consider past history of hypertension, treated or untreated), or both. Therapeutic options should include IV fluids, treatment of congestive heart failure and bradycardia, and consideration of pressor agents such as dopamine.

American Academy of Neurology blue dot bullet American Association of Neurological Surgeons
American Association of Neuroscience Nurses blue dot bullet American College of Emergency Physicians
American Society of Neuroradiology blue dot bullet American Stroke Association, a Division of American Heart Association
Centers for Disease Control and Prevention blue dot bullet Congress of Neurological Surgeons
National Association of Chronic Disease Directors blue dot bullet National Association of EMS Physicians
National Association of State EMS Officials
National Institute of Neurological Disorders and Stroke blue dot bullet National Stroke Association
Neurocritical Care Society blue dot bullet Society of NeuroInterventional Surgery
Stroke Belt Consortium blue dot bullet Veterans Administration