Hypertension is the major risk factor for stroke. When patients present with an acute stroke of ischemic or hemorrhagic type, and have elevated blood pressure, there is a dilemma concerning blood pressure reduction. If the blood pressure remains elevated, this may worsen arterial blood vessel wall injury and increase cerebral edema; however if blood pressure is reduced, this may reduce cerebral perfusion pressure and worsen neurological deficit. A review of the existing literature on this controversial issue is presented.