Six cases with acute onset of neurological symptoms and extremely high blood pressure (BP) are reviewed. Hypertensive crisis or stroke were the main differential diagnoses. According to what is advocated for both situations, prompt antihypertensive therapy was instituted. Although recommended doses of hydralazine, reserpine or furosemide were given, the systolic BPs fell to less than 100 mmHg. Intracerebral hemorrhage or infarction was subsequently established in all patients and only one survived. Convincing evidence for a beneficial effect of BP reduction in acute stroke is lacking. Our data indicate excessive response to therapy in some patients. Also, moderate lowering of BP might reduce cerebral blood flow in these patients, often chronically hypertensive and with raised intracranial pressure. Extreme caution with antihypertensive therapy seems therefore warranted if the diagnosis of hypertensive crisis is not certain and a stroke is suspected.