Patient description: A 62-year-old African-American man presented with left upper and lower extremity weakness, associated with dark visual spot in right eye, right facial numbness, facial drop and slurred speech. He denied dyspnea, headache, palpitations, chest pain, fever, dizziness, bowel or urinary incontinence, loss of consciousness. His medical history was significant for hypertension, hyperlipidemia and hypothyroidism. He smokes cigarette 1 pack per day for 40 years and alcohol consumption of 5 to 6 beers per week. He is not aware about his family history. He is using Levothyroxine, Atorvastatin and HTCZ. His vital signs were stable in the primary evaluation. Left-sided facial droop, dysarthria, and left-sided hemiplegia were seen in the physical exam. His National Institutes of Health Stroke Scale (NIHSS) score was calculated as 7. Initial CT angiogram of head and neck reported no acute intracranial findings. Intravenous recombinant tissue plasminogen activator (t-PA) was administered as well as high-dose statin therapy. The patient was admitted to the intensive care unit to be monitored for 24 hours. MRI of the head revealed an acute 1.7-cm infarct of the right periventricular white matter and posterior right basal ganglia.

Clinical trial eligibility criteria: eligible ages (years): 21.0-80.0,  Blood Pressure Acute Stroke Disabling neurological deficit (NIHSS minimum 4 points) due to stroke IV thrombolysis initiated within 4.5 hours of symptom-onset No hemorrhage on baseline non-contrast head CT scan At least two consecutive BP measurements (taken at ≥5 min apart) of 160-185mmHg (systolic) and 90 -105mmHg (diastolic) at the time of randomization (BP >185/105mmHg would be treated as standard of care in patient treated with IV-TPA) Patients between 21-80 years of age, either gender and all ethnicities would be eligible for inclusion. Consent for participation in this study would be obtained from the patient. In patients unable to give consent due to speech or mental disabilities due to stroke, consent would be obtained from the nearest relative Although, men and women of reproducible age would be enrolled, all contraception methods would be allowed once they are physically fit  Patients considered ineligible for IV-TPA. Patients treated with mechanical thrombectomy) would not be included Symptomatic occlusion or >70% stenosis of the internal carotid artery Patients with impaired CVR on TCD. Vasodilatory reserve would be evaluated with the hypercapnoeic challenge (voluntary breath-holding for 30 seconds and monitoring of the mean flow velocities of both MCAs. In patients who are aphasic or unable to hold breath, the hypercapnoeic challenge would consist of subjecting these patients to re-breathe in a closely fit oxygen mask connected with air bag and a capnometer. Our lab has already validated this method against voluntary breath holding test and acetazolamide challenged SPECT. Patients with an impaired CVR (breath holding index <0.69) would be excluded from the study since this figure is associated with an increased risk of stroke due to cerebral hypoperfusion Patients with severe intracranial stenosis Conditions requiring urgent antihypertensive treatment independent of BP levels (acute myocardial infarction, severe left ventricular heart failure, aortic dissection, acute renal failure, acute pulmonary oedema and hypertensive encephalopathy) Functional dependence prior to the acute stroke quantified as a mRS-score of >1 Contraindications to Labetalol for example history of asthma, right-sided congestive heart failure, bradycardia, and heart block