This review summerize evidence on pharmacological approaches to prevent HT, with emphasis on interventions that stabilise the neurovascular unit, modulate inflammatory injury, and support risk-informed treatment decisions. Pharmacological prevention can be conceptualised in three tiers: (i) BBB-directed therapies that reinforce endothelial barrier programmes; (ii) optimised reperfusion pharmacology, where thrombolytic selection and protocolised physiological management reduce avoidable bleeding risk; and (iii) adjunct neuroprotective and immunomodulatory strategies, including PSD-95 pathway modulation and antioxidant or anti-inflammatory. Precision frameworks are advancing through biomarkers that reflect proteolytic vulnerability (e.g., MMP-9), BBB structural injury (tight-junction proteins), and thromboinflammatory markers (e.g., clot S100B), supporting pathway-tailored monitoring. Overall, integrating BBB-stabilising pharmacology with optimised acute pathways and biomarker-guided strategies represents a promissing breakthrough to reduce HT without decreasing reperfusion efficacy.