Blood pressure management and optimizing care in acute ischemic stroke

Acute ischemic stroke is a major cause of death and disability worldwide. This thesis investigates strategies to optimize acute and subacute care for patients with ischemic stroke, with a particular focus on blood pressure management.
The first part addresses several aspects of stroke care and outcomes. We demonstrate that initiating blood pressure-lowering treatment at least 48 hours after ischemic stroke reduces the risk of recurrent stroke and other major vascular events, although intensive blood pressure targets did not yet show additional benefit. We further show that admission hyperglycemia is associated with post-stroke infections and poor functional outcome, although infections did not explain this latter association. Admission outside office hours was associated with slightly longer treatment times and marginally worse functional outcomes. Finally, we found the Mann-Whitney measure of superiority to be a valid alternative statistical approach for analyzing functional outcomes and demonstrated that its performance can be improved through propensity score-based stratification.
The second part focuses on blood pressure treatment strategies in ischemic stroke patients prior to intravenous thrombolysis. Approximately one in five otherwise eligible patients presents with blood pressure above the recommended threshold of 185/110 mmHg. In the prospective TRUTH study, we found no significant difference between an active blood pressure lowering strategy and not lowering it before thrombolysis. Nevertheless, functional outcomes showed a clear trend favoring the non-lowering strategy. These findings challenge current clinical practice and highlight the need for randomized trials to establish the optimal blood pressure management strategy in this specific patient population.