Intensive Versus Standard Blood Pressure Control After Endovascular Thrombectomy in Acute Ischemic Stroke: A Meta‐Analysis of Randomized Controlled Trials

Abstract

Background

The optimal strategy for blood pressure management following mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion remains a subject of ongoing research.

Methods

We comprehensively searched PubMed, Embase, and the Cochrane Library from inception to June 20, 2025. Randomized controlled trials comparing intensive versus standard blood pressure control following mechanical thrombectomy for acute ischemic stroke were included. The primary outcomes were excellent functional outcome (modified Rankin Scale score 0–1 at 90 days) and good functional outcome (modified Rankin Scale score 0–2 at 90 days). Pooled odds ratios (ORs) with 95% CIs were calculated using a random‐effects model.

Results

A total of 6 randomized controlled trials were included. The pooled estimates indicated that intensive blood pressure control was associated with lower rates of good functional outcome (OR, 0.70 [95% CI, 0.54–0.91]), an increased likelihood of all‐cause mortality (OR, 1.21 [95% CI, 1.05–1.40]), and a higher incidence of hypotensive episodes (OR, 2.49 [95% CI, 1.56–3.96]). No significant differences were found in excellent functional outcome (OR, 0.91 [95% CI, 0.67–1.23]) or symptomatic intracranial hemorrhage (OR, 1.19 [95% CI, 0.89–1.61]). The overall strength of evidence was high for functional outcomes and hypotensive episodes, whereas it was moderate for all‐cause mortality and symptomatic intracranial hemorrhage.

Conclusions

This meta‐analysis demonstrates that intensive blood pressure control following mechanical thrombectomy does not improve functional outcomes and may be associated with harm, including reduced rates of good functional outcome, increased all‐cause mortality, and a higher incidence of hypotensive episodes.

Nonstandard Abbreviations and Acronyms

BEST‐II

Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke

BP‐TARGET

Safety and Efficacy of Intensive Blood Pressure Lowering After Successful Endovascular Therapy in Acute Ischaemic Stroke

DETECT

Blood Pressure Management in Stroke Following Endovascular Treatment

ENCHANTED2/MT

Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischaemic Stroke/Mechanical Thrombectomy

GRADE

Grading of Recommendations, Assessment, Development, and Evaluation

IDENTIFY

Early Intensive Blood Pressure Management After Endovascular Treatment in Ischaemic Stroke

MT

Mechanical Thrombectomy

OPTIMAL‐BP

Outcome in Patients Treated With Intra‐Arterial Thrombectomy–Optimal Blood Pressure Control

PROSPERO

International Prospective Register of Systematic Reviews

SBP

systolic blood pressure

sICH

symptomatic intracranial hemorrhage

Clinical Perspective.

What Is New?

• This meta‐analysis of 6 randomized controlled trials encompassing 1902 patients with acute ischemic stroke treated with mechanical thrombectomy demonstrates that intensive blood pressure lowering (<130–140 mm Hg) after mechanical thrombectomy does not improve functional outcomes.

• Intensive blood pressure control was associated with a significantly lower likelihood of achieving good functional recovery (modified Rankin Scale score 0–2 at 90 days), higher all‐cause mortality, and an increased incidence of hypotensive episodes.

What Are the Clinical Implications?

• Postthrombectomy blood pressure management should be approached cautiously, as intensive systolic blood pressure reduction (<130–140 mm Hg) does not improve functional recovery and may increase the risk of hypotension and mortality.

Endovascular thrombectomy remains the cornerstone of acute ischemic stroke management due to large vessel occlusion. ¹ , ² However, a substantial proportion of patients fail to achieve satisfactory functional recovery. ³ , ⁴ , ⁵ Among the various factors contributing to this limited recovery, postrecanalization blood pressure has been identified as a key determinant associated with functional outcomes. ⁶ According to the current guidelines from the American Heart Association/American Stroke Association, systolic blood pressure (SBP) and diastolic BP should be maintained at or below 180/105 mm Hg for at least 24 hours following recanalization to optimize neurological recovery and minimize the risk of complications. ¹ Recently, a number of randomized controlled trials (RCTs) have investigated intensive BP control strategies, typically targeting an SBP of <140 mm Hg, ⁷ , ⁸ , ⁹ with some studies aiming for thresholds as low as 130 mm Hg. ¹⁰ , ¹¹ , ¹²

Although elevated BP is frequently observed in patients with acute ischemic stroke due to neurogenic and cerebral autoregulatory mechanisms, observational data have suggested that lower SBP may be associated with improved functional recovery. ¹³ , ¹⁴ , ¹⁵ Moreover, a linear relationship between SBP and functional outcomes has been reported in patients who achieve successful recanalization. ¹⁶ Data from randomized controlled trials, including OPTIMAL‐BP ⁷ (Outcome in Patients Treated With Intra‐Arterial Thrombectomy–Optimal Blood Pressure Control) and ENCHANTED2/MT (Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischaemic Stroke/Mechanical Thrombectomy), ¹¹ demonstrated a higher degree of functional impairment in patients who underwent intensive BP management following mechanical thrombectomy (MT). However, these findings have not been consistently supported by subsequent trials, ⁸ , ⁹ , ¹⁰ , ¹² indicating ongoing debate regarding the benefits of aggressive BP control in this setting.

The findings from the IDENTIFY (Early Intensive Blood Pressure Management After Endovascular Treatment in Ischaemic Stroke) trial have been published recently. ¹² Given the heterogeneity of existing evidence, the limited sample sizes of individual studies, and the insufficient analytical depth of prior meta‐analyses, ¹⁷ , ¹⁸ we aim to conduct a comprehensive systematic review and meta‐analysis of available data from randomized controlled trials to inform and enhance clinical decision‐making.

METHODS

This meta‐analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines ¹⁹ (Table S1). The protocol for this meta‐analysis has been registered on International Prospective Register of Systematic Reviews (CRD420251082965). As this review did not involve any direct patient data collection or investigation by the authors, ethical approval was not needed. The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Literature Search

We conducted a comprehensive search of the Cochrane Central Register of Controlled Trials, PubMed, and Embase databases, as well as registered trial repositories, from their inception to June 25, 2025. The search strategy used a combination of targeted keywords and Medical Subject Headings terms, such as “acute ischemic stroke,” “blood pressure control,” “mechanical thrombectomy,” and “RCT.” Boolean operators (AND, OR) were applied to optimize the search and ensure the inclusion of all relevant studies. Further details regarding the search terms and strategy are provided in Table S2.

Eligibility Criteria

The inclusion criteria for this review were as follows: (1) study design—RCTs; (2) population—patients diagnosed with acute ischemic stroke resulting from large vessel occlusion; (3) intervention—intensive BP control; (4) comparator—standard BP control; and (5) outcome—reporting at least 1 relevant outcome of interest.

Studies were excluded if they were not RCTs, experimental studies, post hoc analyses, or observational studies.

Study Selection and Data Extraction

Rayyan software was used to screen and remove duplicates from the studies identified in the online search. Following duplicates removal, 2 authors (H. A. and M. A.) independently carried out title and abstract screening. Afterwards, a comprehensive full‐text review was performed by the same authors. In instances of disagreement, a third author (T. M. H.) facilitated resolution.

Study characteristics, such as authors and study locations, inclusion criteria, total population, time from symptom onset to MT, sample size, age, sex, comorbidities (diabetes, hypertension, stroke/transient ischemic attack or atrial fibrillation), prestroke modified Rankin Scale (mRS) score, and baseline National Institutes of Health Stroke Scale score were extracted. The primary outcome was excellent functional outcome (mRS score 0–1 at 90 days) and good functional outcome (mRS score 0–2 at 90 days). The secondary outcomes included all‐cause death at 90 days, symptomatic intracranial hemorrhage (sICH), and hypotensive episodes. A list of common variable definitions has been provided in Table S3. Detailed inclusion and exclusion criteria of each trial are presented in Table S4. The specific definitions and protocols for intensive and standard BP control applied across the included trials are provided in Table S5.

Quality Assessment

The risk of bias for all included trials was assessed using the Cochrane Risk of Bias 2.0 tool ²⁰ and categorized as low, high, or raising some concerns. Two independent reviewers (T. M. H. and H. A.) conducted the assessments, and any disagreements were resolved through discussion with a third reviewer (R. A.).

Statistical Analysis

Statistical analysis was conducted using R version 4.41, using the ‘meta’ package. Odds ratios (ORs) with 95% CIs were calculated as summary statistics, using a random‐effects model. Between‐study variance (τ²) was estimated using the restricted maximum likelihood method. To improve the accuracy of CIs in the context of a limited number of included studies, we applied the Hartung‐Knapp‐Sidik‐Jonkman adjustment, ²¹ incorporating the Jackson et al. hybrid method 2 as an ad hoc correction. ²² , ²³ The I² statistic was used to assess statistical heterogeneity across the trials, with a value of 50% considered indicative of substantial heterogeneity. Publication bias could not be evaluated using funnel plots or statistical tests due to the limited number of pooled studies (<10). To account for the distribution of true effect sizes across studies, a 95% prediction interval was calculated. A sensitivity analysis using the leave‐one‐study method was conducted, sequentially excluding each study from the pooled analysis to evaluate its effect on the overall results. P values were 2 sided with a significance threshold of <0.05.

Certainty of Evidence Assessment

The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation on the GRADE Working Group guidelines; the certainty of the pooled estimates was rated as high, moderate, low, or very low (Table S6).

RESULTS

Study Selection

A total of 204 records were identified from the databases, including PubMed (41), Cochrane (32), Embase (128), citation searching (1) and gray literature sources (2). After excluding 32 duplicate entries, 169 records were screened based on their titles and abstracts. Of these, 161 records were excluded, and the remaining studies underwent full‐text assessment for eligibility. Finally, 6 RCTs were deemed eligible and included in the final analysis (Figure 1).

Figure 1. PRISMA 2020 flowchart.

PRISMA indicates Preferred Reporting Items for Systematic Reviews and Meta‐analyses.

Characteristics of Included Studies

A total of 6 RCTs were included, conducted across France, ¹⁰ China, ¹¹ the United States, ⁹ South Korea, ⁷ Canada, ⁸ and China ¹² with a combined total of 1902 participants, with 944 patients in the intensive BP control group and 958 in the standard BP control group. The median follow‐up was 90 days. In most of the included trials, randomization to BP control strategies was conducted within 24 hours of symptom onset. However, the IDENTIFY ¹² trial exclusively investigated an early intensive approach, with randomization occurring within 6 hours of symptom onset. The mean ages of the intensive BP control group were 75 years and 73 years for the standard control group. Additional characteristics, including sex distribution, time from symptom onset to MT, mean SBP before MT, past medical history, baseline National Institutes of Health Stroke Scale score, and modified thrombolysis in cerebral infarction score, are detailed in Table. Overall, 4 ⁷ , ⁹ , ¹⁰ , ¹² of the 6 trials were judged to have some concerns regarding risk of bias. Two trials—ENCHANTED2/MT 2022 ¹¹ and DETECT (Blood Pressure Management in Stroke Following Endovascular Treatment) 2024 ⁸ —were assessed as having a low overall risk. No study was rated as having a high risk of bias. The most frequently noted concerns were related to the randomization process (D1), outcome measurement (D4), and selection of the reported results (D5). A comprehensive summary of the risk of bias assessment is provided in Figure S1.

Table 1.

Baseline Characteristics of Included Studies

Trial	BP‐TARGET 2021	ENCHANTED2/MT 2022	BEST‐II 2023	OPTIMAL‐BP 2023	DETECT 2024	IDENTIFY 2025
Study location	France	China	United States	South Korea	Canada	China
Intensive SBP target, mm Hg	100–129	<120	Group A: <140 Group B: <160	<140	<140	<130
Standard SBP target, mm Hg	130–185	140–180	≤ 180	140–180	<180	<180
Mean SBP before endovascular thrombectomy, mm Hg
Intensive	155	158.1	Group A: 150 Group B: 151	NR	168	150
Standard	152	158.7	146	NR	162	152
Median follow‐up	90 d	90 d	90 d	90 d	90 d	90 d
Location of occlusion	MCA, ICA	MCA, ICA	MCA, ICA	MCA, ICA	MCA, ICA	MCA, ICA
Patients receiving intravenous thrombolysis
Intensive	85	132	Group A: 17 Group B: 19	44	6	77
Standard	83	115	19	54	4	85
Reperfusion grade: modified thrombolysis in cerebral infarction 3
Intensive	88	342	Group A: 18 Group B: 18	NR	8	144
Standard	84	340	16	NR	7	162
Sample size
Intensive	158	407	Group A: 40 Group B: 40	155	15	183
Standard	160	409	40	147	15	200
Time interval between stroke onset to reperfusion, min
Intensive	285 (234–357)	438 (276–654)	Group A: NR Group B: NR	421 (265.5–772)	331 (249–835)	293 (237–365)
Standard	297 (220–353)	438 (276–654)	NR	399 (250–757.5)	310 (247–628)	273 (209–344)
Age, y
Intensive	76±14.2	68±12	Group A: 75.2±15.8 Group B: 69.4±10.9	73.2±12.1	86±10.6	72±11
Standard	73.3±14.9	67±12	67.4±14	72.9±10.8	76.3±10.6	72±10
Male/female sex
Intensive	81/77	249/158	Group A: 28/12 Group B: 19/23	92/63	6/9	91/92
Standard	72/82	257/152	20/20	88/59	7/8	107/93
Past medical history
Diabetes, n
Intensive	34	81	Group A: 12 Group B: 15	65	3	49
Standard	33	82	13	62	5	45
Hypertension, n
Intensive	110	267	Group A: 32 Group B: 28	121	14	134
Standard	113	261	32	110	11	134
Atrial fibrillation, n
Intensive	NR	84	Group A: 19 Group B: 13	77	7	112
Standard	NR	98	21	69	5	121
Stroke/transient ischemic attack, n
Intensive	25	107	Group A: NR Group B: NR	36	6	29
Standard	21	139	NA	30	2	37
Prestroke modified Rankin Scale score of 1 (%)
Intensive	NR	18	Group A: 22.5 Group B: 15	NR	0	NR
Standard	NR	19	15	NR	0	NR
Baseline National Institutes of Health Stroke Scale score
Intensive	16.7±6	15±7.4	Group A: 16.7±4.2 Group B: 18.7±6.2	11.3±7.2	18.7±5.7	15.7±5.2
Standard	16.7±5.2	15±7.4	14±4.6	9±7	18±8.2	15±4.5

BEST‐II indicates Blood Pressure After Endovascular Stroke Therapy‐II; BP‐TARGET, Safety and Efficacy of Intensive Blood Pressure Lowering After Successful Endovascular Therapy in Acute Ischaemic Stroke; DETECT, Blood Pressure Management in Stroke Following Endovascular Treatment; ENCHANTED2/MT, Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischaemic Stroke/Mechanical Thrombectomy; ICA, internal carotid artery; IDENTIFY, Early Intensive Blood Pressure Management After Endovascular Treatment in Ischaemic Stroke; MCA, middle cerebral artery; NR, not reported; OPTIMAL‐BP, Outcome in Patients Treated With Intra‐Arterial Thrombectomy–Optimal Blood Pressure Control; and SBP, systolic blood pressure.

Primary Outcomes

Excellent Functional Outcome

The pooled analysis from 6 RCTs ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² demonstrated comparable results for excellent functional outcome between intensive and standard BP control (OR, 0.91 [95% CI, 0.67–1.23]; P=0.44, I²=23%, high certainty) (Figure 2). Leave‐one‐out sensitivity analyses demonstrated that the exclusion of the BP‐TARGET (Safety and Efficacy of Intensive Blood Pressure Lowering After Successful Endovascular Therapy in Acute Ischaemic Stroke), and ENCHANTED2/MT trials individually resulted in a reduction of heterogeneity (I²) to 3% and 0% respectively (Figure S2).

Figure 2. Forest plot for excellent functional outcome.

The pooled odds ratio was 0.91 (95% CI, 0.67–1.23), indicating no significant difference between intensive and standard blood pressure control (P=0.44). Heterogeneity was low (I²=23%). BEST‐II indicates Blood Pressure After Endovascular Stroke Therapy‐II; BP‐TARGET, Safety and Efficacy of Intensive Blood Pressure Lowering After Successful Endovascular Therapy in Acute Ischaemic Stroke; DETECT, Blood Pressure Management in Stroke Following Endovascular Treatment; ENCHANTED2/MT, Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischaemic Stroke/Mechanical Thrombectomy; IDENTIFY, Early Intensive Blood Pressure Management After Endovascular Treatment in Ischaemic Stroke; mRS, modified Rankin Scale; OPTIMAL‐BP, Outcome in Patients Treated With Intra‐Arterial Thrombectomy–Optimal Blood Pressure Control; and OR, odds ratio.

Good Functional Outcome

The pooled analysis from 6 RCTs ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² demonstrated that patients who received intensive BP control had lower odds of achieving good functional outcome as compared with standard BP control (OR, 0.70 [95% CI, 0.54–0.91]; P=0.02, I²=10%, high certainty) (Figure 3). Leave‐one‐out sensitivity analysis showed that the overall effect size remained relatively stable (Figure S3). The I² reduced to 0 upon exclusion of BP‐TARGET and ENCHANTED2/MT trials respectively (Figure S3).

Figure 3. Forest plot for good functional outcome.

The pooled odds ratio was 0.70 (95% CI, 0.54–0.91), showing significantly lower odds of good outcome with intensive blood pressure control (P=0.02). Heterogeneity was low (I²=10%). BEST‐II indicates Blood Pressure After Endovascular Stroke Therapy‐II; BP‐TARGET, Safety and Efficacy of Intensive Blood Pressure Lowering After Successful Endovascular Therapy in Acute Ischaemic Stroke; DETECT, Blood Pressure Management in Stroke Following Endovascular Treatment; ENCHANTED2/MT, Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischaemic Stroke/Mechanical Thrombectomy; IDENTIFY, Early Intensive Blood Pressure Management After Endovascular Treatment in Ischaemic Stroke; mRS, modified Rankin Scale; OPTIMAL‐BP, Outcome in Patients Treated With Intra‐Arterial Thrombectomy–Optimal Blood Pressure Control; and OR, odds ratio.

Secondary Outcomes

All‐Cause Death

Our pooled analysis from 6 RCTs ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² demonstrated that patients who received intensive BP control had higher odds of all‐cause death compared with those who received standard BP control (OR, 1.21 [95% CI, 1.05–1.40]; P=0.02, I²=0%, moderate certainty) (Figure 4). The leave‐one‐out sensitivity analysis showed that the overall effect size remained relatively stable (Figure S4).

Figure 4. Forest plots for all‐cause death (90‐d mortality).

The pooled odds ratio was 1.21 (95% CI, 1.05–1.40), indicating higher 90‐d mortality in the intensive blood pressure control group (P=0.02). BEST‐II indicates Blood Pressure After Endovascular Stroke Therapy‐II; BP‐TARGET, Safety and Efficacy of Intensive Blood Pressure Lowering After Successful Endovascular Therapy in Acute Ischaemic Stroke; DETECT, Blood Pressure Management in Stroke Following Endovascular Treatment; ENCHANTED2/MT, Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischaemic Stroke/Mechanical Thrombectomy; IDENTIFY, Early Intensive Blood Pressure Management After Endovascular Treatment in Ischaemic Stroke; OPTIMAL‐BP, Outcome in Patients Treated With Intra‐Arterial Thrombectomy–Optimal Blood Pressure Control; and OR, odds ratio.

Symptomatic Intracranial Hemorrhage

The analysis demonstrated a nonstatistically significant trend toward a higher incidence of sICH with intensive BP control compared with standard BP control (OR, 1.19 [95% CI, 0.89–1.61]; P=0.19, I²=0%, moderate certainty) (Figure 5A). ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² Leave‐one‐out sensitivity analysis did not reveal any significant findings (Figure S5). A sensitivity analysis was also conducted using Peto's fixed‐effects model and demonstrated comparable results (Figure S6).

Figure 5. Forest plots for (A) sICH, the pooled odds ratio was 1.19 (95% CI, 0.89–1.61), suggesting no significant difference in sICH between intensive and standard BP control (P=0.19) and (B) hypotensive episodes, the pooled odds ratio was 2.49 (95% CI, 1.56–3.96), showing a significantly higher risk of hypotensive events with intensive BP control (P=0.01).

BEST‐II indicates Blood Pressure After Endovascular Stroke Therapy‐II; BP, blood pressure; BP‐TARGET, Safety and Efficacy of Intensive Blood Pressure Lowering After Successful Endovascular Therapy in Acute Ischaemic Stroke; DETECT, Blood Pressure Management in Stroke Following Endovascular Treatment; ENCHANTED2/MT, Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischaemic Stroke/Mechanical Thrombectomy; IDENTIFY, Early Intensive Blood Pressure Management After Endovascular Treatment in Ischaemic Stroke; mRS, modified Rankin Scale; OPTIMAL‐BP, Outcome in Patients Treated With Intra‐Arterial Thrombectomy–Optimal Blood Pressure Control; OR, odds ratio; and sICH, symptomatic intracranial hemorrhage.

Hypotensive Episodes

The pooled analysis from 3 RCTs ⁷ , ¹⁰ , ¹² demonstrated that patients in the intensive BP control group had higher odds of experiencing hypotensive episodes compared with standard BP treatment (OR, 2.49 [95% CI, 1.56–3.96]; P = 0.01, I² = 0%, high certainty) (Figure 5B). Leave‐one‐out sensitivity analysis did not reveal any significant findings (Figure S7).

DISCUSSION

In this meta‐analysis, we evaluated the efficacy and safety of intensive versus standard blood pressure control following MT in patients with acute ischemic stroke due to large vessel occlusion. Our study demonstrated with high certainty of evidence that intensive BP control did not improve the odds of achieving an excellent functional outcome (mRS score 0–1) compared with standard BP control, whereas it was associated with significantly lower odds of achieving a good functional outcome (mRS score 0–2). Intensive BP control was further associated with a higher risk of all‐cause mortality (moderate certainty evidence) and a significantly increased incidence of hypotensive episodes (high certainty evidence). There was a nonsignificant trend toward higher rates of symptomatic intracranial hemorrhage with intensive BP lowering.

The finding that intensive BP control did not improve excellent functional outcomes and, in fact, led to lower odds of good functional outcomes and higher all‐cause mortality, aligns with recent evidence suggesting potential harm from overly aggressive BP reduction. ¹⁸ , ²⁴ , ²⁵ For instance, the largest trial to date on this subject (ENCHANTED2/MT trial) was terminated early due to safety concerns in the intensive BP‐lowering group, with patients experiencing worse mRS scores and health‐related quality of life at 3 months, along with a higher incidence of severe disability or death. ¹¹ This trial, included in our meta‐analysis, highlights the risks associated with targeting very low SBP (<120 mm Hg) after MT. Similarly, prior meta‐analyses ¹⁸ , ²⁵ also concluded that intensive postendovascular thrombectomy BP reduction does not yield benefits and may carry risks, favoring a conservative management strategy.

The increased incidence of hypotensive episodes in the intensive BP control group is a plausible mechanism for the observed negative outcomes. Hypotension, particularly in the context of impaired cerebral autoregulation post stroke, can lead to reduced cerebral perfusion, potentially extending the ischemic penumbra and exacerbating neurological injury. ²⁶ , ²⁷ , ²⁸ This is especially relevant in patients with underlying conditions such as chronic hypertension or intracranial atherosclerosis, where cerebral autoregulation may be further compromised. ²⁷ , ²⁹ , ³⁰ The nonsignificant trend toward increased sICH with intensive BP control remains a concern given the potential for severe consequences. Other studies have also highlighted the delicate balance between preventing hemorrhagic transformation and maintaining adequate cerebral perfusion. ³¹ , ³² , ³³ , ³⁴ Conversely, the BP‐TARGET trial did not find a benefit to intensive BP lowering regarding the risk of sICH, and it was not sufficiently powered to detect differences in functional outcomes. ¹⁰ These findings suggest that although intensive BP lowering may not significantly increase the risk of sICH, it also fails to confer protective benefits and may, in fact, impair functional recovery through hypoperfusion‐related mechanisms. Therefore, our results reinforce current guidelines recommending the maintenance of SBP <180 mm Hg during the first 24 hours after MT, while avoiding excessive reductions <130 to 140 mm Hg that may compromise cerebral perfusion and neurological outcomes. ¹ , ³⁵

One crucial aspect highlighted in the context of intensive BP management is the timing of intervention. The IDENTIFY 2025 trial explored that if intensive treatment is administered within 6 hours of MT, functional recovery is likely. ¹² Consequently, this trial was uniquely designed to examine an early intensive approach (within 6 hours), setting it apart from other trials where randomization to standard or intensive BP control regimens was permitted up to 24 hours after MT. This distinction in the treatment window is vital, as it suggests that the benefits or risks of intensive BP control may be highly dependent on the immediacy of the intervention following successful recanalization. The findings from trials like ENCHANTED2/MT, which showed worse outcomes with intensive BP lowering, might be influenced by the broader time window for intervention compared with the focused early approach of IDENTIFY 2025. This emphasizes the need for future research to precisely define the optimal time window for intensive BP management post MT to maximize functional recovery while minimizing adverse events.

Limitations

Our meta‐analysis has some limitations. The heterogeneity in the definition of “intensive” and “standard” BP control across the included trials, although addressed by classifying the BEST‐II (Blood Pressure After Endovascular Stroke Therapy‐II) trial's <140 mm Hg group as intensive, could still introduce some variability. The specific timing of BP intervention, as highlighted by the IDENTIFY 2025 trial, is a critical factor that could not be fully explored due to variations in reporting across studies. Furthermore, although we included studies on MT, the underlying causes of stroke and patient comorbidities varied, which could influence BP response and outcomes. Future meta‐analyses with individual patient data would allow for more granular analysis of these factors and a more precise understanding of optimal BP targets in specific patient subgroups.

Clinical Implications and Future Research Directions

Our findings reinforce current guidelines ² advocating for a more conservative BP management strategy (eg, SBP <180 mm Hg) in the postthrombectomy period. ⁶ The unique contribution of this meta‐analysis lies in its comprehensive inclusion of recent RCTs, including the IDENTIFY trial. Although our study provides robust evidence against intensive BP lowering, further research is warranted to precisely define optimal individualized BP targets, considering factors such as cerebral autoregulation, stroke cause, and the timing of intervention, as highlighted by the IDENTIFY trial's focus on early intensive treatment.

Given the complexities of postthrombectomy BP management, several avenues for future research emerge. The unique design of the IDENTIFY 2025 trial, focusing on early intensive treatment within 6 hours of MT, suggests that the timing of intervention is paramount. Future RCTs may be designed to investigate the optimal time window for initiating intensive BP control, as well as the ideal duration of such interventions. ³⁴ Personalized BP management strategies, taking into account individual patient characteristics such as cerebral autoregulation status, stroke cause, and collateral circulation, are also crucial. ³ The mechanistic basis of postthrombectomy BP management is inherently complex and involves multiple interrelated pathophysiological processes. ¹⁰ Elevated BP may exacerbate reperfusion injury, cerebral edema, and the risk of hemorrhagic transformation; however, excessive reduction in BP can compromise collateral flow and reduce perfusion to the ischemic penumbra, particularly in patients with impaired cerebral autoregulation or incomplete recanalization. ³⁶ Therefore, the objective of postendovascular thrombectomy BP optimization extends beyond the prevention of hemorrhage—it seeks to achieve a delicate balance between minimizing vascular injury and preserving adequate cerebral perfusion to promote optimal neurological recovery. Advanced imaging techniques could help identify patients who might benefit from more aggressive BP lowering or, conversely, those at higher risk of hypoperfusion. Finally, research into the specific antihypertensive agents and their impact on SBP variability and outcomes is warranted, as different agents may have varying effects on cerebral hemodynamics.

CONCLUSIONS

This meta‐analysis demonstrates that intensive BP control following MT for acute ischemic stroke due to large vessel occlusion does not confer benefit in achieving excellent functional outcome and is associated with significantly lower odds of good functional recovery, higher all‐cause mortality, and increased risk of hypotensive episodes. These findings reinforce current guideline recommendations favoring a more conservative BP management strategy in the postthrombectomy period. The evidence highlights the importance of avoiding overly aggressive BP reduction, particularly in the context of impaired cerebral autoregulation. Future research should prioritize defining optimal timing and individualized targets for BP control to balance the risks of hypoperfusion and hemorrhagic transformation and improve outcomes in this high‐risk population.

Sources of Funding

None.

Disclosures

Dr Fonarow reports consulting for Abbott, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Eli Lilly, Johnson & Johnson, Medtronic, Merck, Novartis, and Pfizer. Dr Hassan reports serving as a consultant or speaker for Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care, Galaxy Therapeutics, Route 92, Perfuze, CorTech, Imago, Shockwave, Toro, NeuroVasX, Xcath, Kaneka and Plaga. He serves as principal investigator for the COMPLETE study—Penumbra, LVO SYNCHRONISE—Viz.ai, MARRS—Perfuze, RESCUE—ICAD—Medtronic and Neva VS Dilate—Vesalio. He is a member of the steering or publication committees for SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI, DISTALS, and Rapid Pulse. Additionally, he serves on the data and safety monitoring board for the COMAND trial. The remaining authors have no disclosures to report.

Supporting information

Tables S1–S6

Figures S1–S7