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Personalized Blood Pressure Targeting After Endovascular Therapy for Acute Ischemic Stroke: A Randomized Clinical Trial.
This randomized clinical trial tested whether setting blood pressure targets after successful clot-removal for large ischemic stroke based on the angiogra…
Signal score47Research triage score
CertaintyModerate (single multicenter RCT with blinded endpoint assessment but open-label intervention; certainty pending full-text verification)Verify in full text
PMID42258192Source identifier
Research triage, not medical advice
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Plain-English signal
This randomized clinical trial tested whether setting blood pressure targets after successful clot-removal for large ischemic stroke based on the angiographic degree of reperfusion (mTICI score) helps patients recover. Patients got a tailored systolic BP range for 72 hours (140-160 mm Hg if mTICI 2b; 100-140 mm Hg if mTICI 2c/3) or usual guideline care (systolic BP <180 mm Hg). At 90 days, 60.0% of people in the tailored group were functionally independent (modified Rankin Scale 0-2) versus 47.1% in the guideline group, an absolute difference of 13.3% favoring the tailored approach. The tailored group also had fewer hemorrhagic transformations (22.3% vs 31.6%). Rates of symptomatic intracranial hemorrhage and 90-day death were similar between groups. The trial suggests a reperfusion-guided BP strategy may improve outcomes after endovascular therapy, but full-text review is needed to confirm methods and applicability before changing practice.
Why it matters
- Addresses optimal post-thrombectomy blood pressure (BP) management for adults with anterior-circulation large-vessel occlusion who achieved successful reperfusion - a common and important decision point in acute stroke care.
- Finds that a reperfusion-guided, individualized systolic BP strategy (different targets for mTICI 2b vs 2c/3) improved 90-day functional outcomes compared with standard guideline BP <180 mm Hg, which could change immediate postprocedural management.
- Reports reduced hemorrhagic transformation with the tailored strategy without increases in symptomatic intracranial hemorrhage or 90-day mortality - potentially shifting the balance of benefits and risks for BP targets after endovascular therapy.
Primary outcomes
- Favorable functional outcome defined as modified Rankin Scale score 0-2 at 90 days (intention-to-treat population)
Effect summary
In the intention-to-treat analysis of 440 patients (mean age 75 years; 53% women), 60.0% (129/215) in the reperfusion-guided BP group versus 47.1% (106/225) in the guideline group achieved mRS 0-2 at 90 days (absolute risk difference 13.3%; 95% CI, 4.1%-22.6%; P = .005). Hemorrhagic transformation occurred in 22.3% vs 31.6% (OR 0.62; 95% CI, 0.41-0.95). Symptomatic intracranial hemorrhage (3.5% vs 3.9%) and 90-day mortality (15.4% vs 15.6%) were similar. Serious adverse events were reported in 15.8% vs 12.0% of patients, respectively.
Benefit-cost lens
| Quick take | Randomized trial reports clinically meaningful absolute increase in independence at 90 days and reduced hemorrhagic transformation using a reperfusion-guided BP regimen versus guideline BP <180 mm Hg for 72 hours. |
|---|---|
| BCR anchor | 2 |
| Time horizon | 3 |
| Discount rate | 0.03 |
| Assumptions | Abstract-only review; assumes trial conduct and results as reported in abstract. Full-text review required to confirm protocol adherence, crossover, per-protocol results, BP control achieved, resource use, subgroup effects, and statistical analysis details. |
Benefit-cost fields are assumptions-based unless explicitly source-derived. Treat them as prompts for deeper economic review.
Risk of bias
| Tool | Rapid-abstract-based appraisal |
|---|---|
| Verdict | Moderate risk of bias |
| Notes | Randomized, open-label with blinded endpoint assessment. Abstract reports ITT analysis and prespecified primary outcome, but open-label treatment and potential performance or cointervention differences could influence results; full-text needed to assess randomization process, allocation concealment, deviations from protocol, completeness of follow-up, and subgroup/per-protocol analyses. |
Harms, equity, conflicts & implementation
| Implementation | Adopting a reperfusion-guided BP protocol would require protocolized BP targets by mTICI score, 72-hour monitoring, availability of antihypertensive agents and vasopressors, trained nursing/medical staff for titration, and local pathway updates. Pilot testing and safety monitoring advised before wide adoption. |
|---|---|
| Equity impact | Unclear from abstract; applicability and equity depend on access to comprehensive stroke centers, monitoring resources, and potential differential effects by age, sex, comorbidity, or pre-stroke disability - full-text subgroup data needed. |
| Harms | Abstract reports similar rates of symptomatic intracranial hemorrhage (3.5% vs 3.9%) and 90-day mortality (15.4% vs 15.6%), but higher serious adverse events in the intervention arm (15.8% vs 12.0%). Full-text needed to characterize nature of serious adverse events, hemodynamic complications, and other harms. |
| Registration | NCT04892511 |
| Replication | Unknown - single multicenter RCT reported here; replication and longer-term or diverse-population studies warranted. |
Source links — verify original
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