Clinical challenges and individualized management of hypertensive emergency complicated by acute ischemic stroke

Rationale: Hypertensive emergency complicated by acute ischemic stroke (AIS) represents a life-threatening clinical condition. Abrupt elevations in blood pressure not only increase the risk of stroke-related complications but also predispose patients to cerebral perfusion imbalance and target-organ injury. However, there is no consensus regarding the optimal antihypertensive strategy or individualized management protocol in this setting. Patient concerns: Three individuals with preexisting chronic hypertension developed acute ischemic stroke in the context of a hypertensive emergency, posing challenges in evaluating disease evolution, optimizing individualized treatment strategies, and assessing long-term prognosis. Diagnoses: Based on clinical manifestations and imaging examinations, all 3 cases were diagnosed as hypertensive emergencies with concomitant AIS. Interventions: In the emergency department, all patients were managed with urapidil administered through a continuous microinfusion pump to achieve blood pressure control. Following stabilization, intravenous thrombolysis was performed in case 1, whereas mechanical thrombectomy was undertaken in cases 2 and 3. Outcomes: After therapeutic intervention, all patients achieved blood pressure stabilization within the target range and demonstrated significant neurological recovery in the acute phase. Cases 1 and 2 demonstrated favorable clinical recovery without major complications during follow-up. Case 3 underwent successful emergency thrombectomy but was transferred to another institution shortly thereafter and was subsequently lost to follow-up. Lessons: Treating hypertensive emergency in the setting of AIS demands careful appraisal of the patient’s condition, hemodynamic profile, and cerebral perfusion needs to guide individualized therapy. Effective yet safe blood pressure reduction is critical to avoid cerebral hypoperfusion. Long-term prognosis can be further optimized through a multidisciplinary team (MDT), close follow-up, strict medication compliance, and targeted lifestyle interventions.