Blood Pressure Management in Acute Ischemic Stroke

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Endovascular thrombectomy (EVT) is the standard acute ischemic stroke treatment due to large-vessel occlusion (LVO), but optimal post-EVT blood pressure (BP) control remains debated.

To assess the association of different systolic blood pressure targets following EVT with functional outcomes, mortality, and complications in patients with AIS due to LVO.

Systematic review and meta-analysis of databases (PubMed, Embase, Web of Science, Scopus, and Cochrane Library) to September 8, 2023.

Inclusion criteria consisted of randomized clinical trials examining post-EVT management of systolic BP in patients with AIS and LVO comparing intensive vs conventional targets. Nonrandomized studies, observational studies, noninterventional trials, meeting abstracts, duplicate studies, studies with overlapping data, and non-English language studies were excluded. Two authors independently applied these criteria through a blinded review, with discrepancies resolved through consensus. The risk of bias in the included studies was assessed using the revised tool for assessing the risk of bias in randomized trials.

This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Three authors extracted data regarding study characteristics, baseline patient data, and outcomes of interest. The pooled data were analyzed using a random-effects meta-analysis.

Rates of functional independence, 90-day mortality, symptomatic intracranial hemorrhage, and hypotensive events.

Results: A total of 4 randomized clinical trials with 1571 initially enrolled patients were included in the analysis. Lower functional independence rates were observed in the intensive control group (relative risk [RR], 0.81 [95% CI, 0.67-0.98]). No significant differences were found in 90-day mortality (RR, 1.18 [95% CI, 0.92-1.52]), symptomatic intracranial hemorrhage (RR, 1.12 [95% CI, 0.75-1.67]), or hypotensive events (RR, 1.80 [95% CI, 0.37-8.76]). There was minimal heterogeneity among the studies included in the functional independence outcome (I2 = 13% and τ2 = 0.003), which was absent among other outcomes (I2 = 0 and τ2 = 0).

These findings suggest that intensive post-EVT BP reduction does not yield benefits and may carry risks. While awaiting the results of additional ongoing trials, a conservative BP management strategy after endovascular recanalization is favored in daily practice ¹⁾

a) for patients with HTN who are otherwise candidates for IV Recombinant human tissue plasminogen activator (tPA): carefully lower SBP to < 185 mm Hg, and DBP to < 110 before giving IV-tPA (Level I), and maintain < 180/105 for 24 hours after tPA (Level I)

b) avoid hypotension and hypovolemia (Level I): no specifics provided.Suggestion:for patients presenting with SBP < 110 or DBP < 70:

● unless contraindicated (viz.: ICH, cerebellar infarction, or decreased cardiac output) gives 250 cc NS over 1 hr, then 500 cc over 4 hrs, then 500 cc over 8 hrs

● if fluid ineffective or contraindicated: consider pressors

c) the benefit of drug-induced hypertension is not well-established in AIS (Level II) ²⁾.

The periprocedural blood pressure management of patients undergoing endovascular thrombectomy can be viewed in two phases relative to the achievement of recanalization. In the hyperacute phase, prior to recanalization, hypotension should be avoided to maintain adequate penumbral perfusion. The American Heart Association Guidelines for the Early Management of Patients With Acute Ischemic Stroke should be followed for the upper end of prethrombectomy blood pressure: ≤185/110 mm Hg, unless post-tissue plasminogen activator administration when the goal is <180/105 mm Hg. After successful recanalization (thrombolysis in cerebral infarction [TICI]: 2b-3), we recommend a target of maximum systolic blood pressure of < 160 mm Hg, while the persistently occluded patients (TICI < 2b) may require more permissive goals up to <180/105 mm Hg. Future research should focus on generating randomized data on optimal blood pressure management both before and after endovascular thrombectomy, to optimize patient outcomes for these divergent clinical scenarios ³⁾.