Blood pressure management in reperfused ischemic stroke

Stroke is the second leading cause of death worldwide and a major contributor to disability, with ischemic strokes accounting for 80% to 85% of all strokes. Appropriate blood pressure management during and after procedures like thrombectomy and thrombolysis is essential, as sustained high blood pressure can worsen outcomes. Guidelines recommend maintaining blood pressure below 180/105 mmHg during the 24 hours after a successful procedure; however, this recommendation is based on low-certainty evidence. Some studies suggest that lowering systolic blood pressure (SBP) to below 160 mmHg could improve outcomes and reduce the risk of intracranial hemorrhage. Given the prevalence of ischemic strokes, establishing optimal blood pressure targets is crucial for minimizing complications, enhancing recovery, and reducing the overall burden on healthcare systems.

To assess the benefits and harms of intensive systolic blood pressure management (target less than 160 mmHg) versus conventional management (target less than 180 mmHg) in people undergoing ischemic stroke reperfusion via systemic thrombolysis or endovascular thrombectomy.

We searched CENTRAL, MEDLINE, Embase, and two trial registers, together with reference checking, citation searching, and contact with study authors, to identify studies. The latest search date was 20 March 2025.

We included randomized controlled trials (RCTs) in adults with acute ischemic stroke reperfused by systemic thrombolysis or endovascular thrombectomy, comparing intensive SBP management (targeting any SBP objective less than 160 mmHg) with conventional SBP management (targeting SBP less than 180 mmHg).

Our critical outcomes were clinical function (assessed dichotomously using the modified Rankin scale (mRS)), quality of life, and neurologic adverse events (assessed as any intracranial hemorrhage (ICH) and as symptomatic ICH). Important outcomes included clinical function (assessed continuously), neurologic status (assessed as a continuous and dichotomous outcome using the National Institutes of Health Stroke Scale (NIHSS)), all-cause mortality, hospital length of stay, and other adverse events.

We used the Cochrane RoB 2 tool to assess risk of bias.

We synthesized results for each outcome using meta-analysis, where possible, with a random-effects model. We used GRADE to assess the certainty of evidence for each outcome.

We included nine studies with 4381 participants, primarily from upper-middle and high-income countries. Seven studies focused on participants who underwent endovascular thrombectomy, while two studies focused on participants who received systemic thrombolysis. Five studies aimed for a target blood pressure of < 140 mmHg, two aimed for < 120 mmHg, one for < 160 mmHg, and another study included two intervention arms with different targets (< 140 mmHg and < 160 mmHg). Eight studies targeted blood pressure < 180 mmHg and one study targeted blood pressure < 160 mmHg in the conventional blood pressure management group.

Intensive blood pressure management versus conventional blood pressure management Critical outcomes Intensive SBP management results in little to no clinically meaningful difference in clinical function (dichotomous outcome) (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.80 to 0.98; I² = 51%; 9 studies, 4272 participants; high-certainty evidence). Intensive SBP management likely results in little to no clinically meaningful difference in quality of life (standardized mean difference (SMD) -0.14, 95% CI -0.49 to 0.22; I² = 75%; 3 studies, 3165 participants; moderate-certainty evidence). For any ICH, intensive SBP management does not increase or reduce neurologic adverse events (RR 0.99, 95% CI 0.87 to 1.14; I² = 30%; 9 studies, 4304 participants; high-certainty evidence). For symptomatic neurologic adverse events (ICH), intensive SBP management may result in little to no clinically meaningful difference (RR 1.03, 95% CI 0.77 to 1.36; I² = 2%; 9 studies, 4304 participants; low-certainty evidence). Important outcomes Intensive SBP management likely results in little to no clinically meaningful difference in clinical function (continuous outcome) (mean difference (MD) 0.28, 95% CI -0.20 to 0.77; I² = 30%; 4 studies, 787 participants; moderate-certainty evidence). It also probably results in little to no clinically meaningful difference in neurologic status (continuous) (MD 1.77, 95% CI 0.37 to 3.16; I² = 10%; 6 studies, 1710 participants; moderate-certainty evidence) and it probably reduces the number of participants with a favorable neurologic status (dichotomous) (RR 0.71, 95% CI 0.51 to 1.01; I² = 0%; 3 studies, 713 participants; moderate-certainty evidence). Additionally, intensive SBP management probably increases all-cause mortality (RR 1.19, 95% CI 1.08 to 1.32; I² = 0%; 9 studies, 4297 participants; moderate-certainty evidence). It also probably results in little to no clinically meaningful difference in hospital length of stay (MD 0.38, 95% CI -1.40 to 2.15; I² = 33%; 5 studies, 3086 participants; moderate-certainty evidence) and it may have little to no clinically meaningful effect on other adverse events (RR 1.21, 95% CI 0.86 to 1.72; I² = 61%; 8 studies, 4012 participants; very low-certainty evidence). Overall, the certainty of the evidence ranged from high to very low across outcomes, with downgrading mainly due to risk of bias, imprecision, and inconsistency; certainty was lowest for symptomatic neurologic adverse events and other adverse events.

Intensive systolic blood pressure management likely results in little to no clinically meaningful differences in quality of life, clinical function (continuous outcome), neurologic status (continuous outcome; NIHSS), or hospital length of stay. It also results in little to no clinically meaningful difference in clinical function (dichotomous) and does not increase or reduce neurologic adverse events. Additionally, it may result in little to no clinically meaningful difference in symptomatic neurologic adverse events and other adverse events. Lastly, it probably reduces the number of participants with a favorable neurologic status (dichotomous outcome) and probably increases all-cause mortality. The certainty of the evidence ranged from very low to high. New studies must identify which patients benefit from different blood pressure strategies through subgroup analyses based on age, baseline blood pressure, and stroke severity, while reporting sex-disaggregated data. Including imaging and physiological markers can help set individualized blood pressure targets. Future trials should involve participants from low- and middle-income countries and consider factors such as access to reperfusion therapy and drug availability.

This Cochrane review had no dedicated funding.

Protocol (2025) available via doi.org/10.1002/14651858.CD016085.