Blood Pressure Management Following Endovascular Stroke Treatment: A Feasibility Trial and Meta-Analysis of Outcomes

Background Although postprocedure blood pressure (BP) correlates with outcome in patients undergoing endovascular thrombectomy (EVT), the optimal target is unknown. Methods We performed a pilot randomized-controlled clinical trial enrolling participants with persistently elevated BP after successful EVT. Participants were randomized within 1 hour from the end of EVT to either intensive (systolic BP target <140 mmHg) or standard BP target (systolic BP <180 mmHg) for 48 hours. The main end point was feasibility, which was assessed with the enrollment rate and adherence to allocated BP target. Exploratory end points included neurologic deterioration, functional improvement, intracranial hemorrhage, and flow dynamics detected by transcranial Doppler ultrasonography. We included the outcomes of our trial in an aggregate data meta-analysis of randomized-controlled clinical trials evaluating the utility of BP control after successful EVT. The primary outcome of the meta-analysis was 3-month good functional outcome, defined as a modified Rankin Scale score of <= 2. Results Between October 23, 2020, and February 4, 2023, 221 patients were screened and 30 were randomized (14%; average recruitment of 1.2 participants/month). Participants in the intensive BP arm had a mean +/- SD systolic BP of 131 +/- 18 mm Hg over 48 hours (75% of the readings were <140 mm Hg), whereas participants in the standard BP arm had a mean +/- SD 48-hour systolic BP of 139 +/- 18 mm Hg (48% of the readings were between 140 and 180 mm Hg). No differences between the 2 groups were documented in any of the predefined exploratory end points. In a meta-analysis of 5 randomized-controlled clinical trials involving 1558 participants, intensive BP control was associated with lower probability for 3-month good functional outcome (odds ratio, 0.66 [95% CI, 0.53-0.82]; I2 = 8%) when compared with standard BP control. Conclusions The natural course of BP normalization following successful recanalization poses challenges to the conduct and success of randomized-controlled clinical trials evaluating different BP thresholds after EVT. Meta-analysis of existing trials suggests harm associated with active BP lowering.