IMPORTANCE: Optimal blood pressure (BP) management after successful endovascular therapy for acute ischemic stroke remains uncertain, as intensive lowering has shown no benefit or potential harm in prior trials.
OBJECTIVE: To determine whether a reperfusion-guided systolic BP control strategy improves functional outcomes compared with guideline-recommended management after successful endovascular therapy for acute ischemic stroke.
DESIGN, SETTING, AND PARTICIPANTS: This investigator-initiated, multicenter, prospective, randomized, open-label clinical trial with blinded end point assessment was conducted among adults with acute ischemic stroke due to anterior circulation large-vessel occlusion who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score =2b) after endovascular therapy at 11 comprehensive stroke centers in Spain between June 14, 2021, and October 1, 2025, with 90-day follow-up. Data analysis was conducted from February 1 to March 12, 2026.
INTERVENTIONS: Participants were randomly assigned (1:1) to a reperfusion-guided systolic BP strategy (140-160 mm Hg for mTICI score of 2b; 100-140 mm Hg for mTICI score of 2c/3) or guideline-recommended management (systolic BP <180 mm Hg) for 72 hours using antihypertensive agents or vasopressors as needed.
MAIN OUTCOMES AND MEASURES: The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale score of 0 to 2 at 90 days, assessed in the intention-to-treat population. Of 446 enrolled patients, 440 were included in the intention-to-treat analysis (mean age, 75 years; 53% women); 6 were excluded due to withdrawal or consent withdrawal.
RESULTS: Among 440 patients (mean [SD] age, 75 [12] years; 233 [53.0%] women), 215 were assigned to the intervention group and 225 to the control group. At 90 days, 129 patients (60.0%) in the intervention group and 106 (47.1%) in the control group achieved a favorable functional outcome (absolute risk difference, 13.3%; 95% CI, 4.1%-22.6%; P = .005). Hemorrhagic transformation occurred in 48 patients (22.3%) in the intervention group and 71 (31.6%) in the control group (odds ratio, 0.62; 95% CI, 0.41-0.95). The rates of symptomatic intracranial hemorrhage (3.5% vs 3.9%) and 90-day mortality (15.4% vs 15.6%) did not differ between groups. Serious adverse events occurred in 34 patients (15.8%) in the intervention group and 27 (12.0%) in the control group.
CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, a reperfusion-guided BP strategy improved functional outcomes and reduced hemorrhagic transformation without increasing major safety events, supporting a tailored approach to postthrombectomy BP management.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04892511.
| Specialty Area | Score |
|---|---|
| Hospital Doctor/Hospitalists | |
| Internal Medicine | |
| Neurology |
Permissive hypertension is a contentious concept and clarity regarding the duration of it and nuances after a procedure like revascularization difficult to figure out. This study looked at repercussion-guided target blood pressure in particular, which is important since patients with reperfusion will have higher likelihood of hemorrhagic transformation due to exposure of the ischemic areas to blood pressure. It makes sense that they have better outcomes with stricter blood pressure controls. This is a well designed RCT with blinded end point assessment.
Interesting study but not very relevant to my clinical practice.
Previous trials targeting a lower-for-all-patients post-EVT have been unsuccessful. This trial suggests that adjusting the target based on reperfusion status improves outcome is welcome. The approach is resource intensive and, if replicated, will lead to a new approach in this setting.
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