Personalized Blood Pressure Targeting After Endovascular Therapy for Acute Ischemic Stroke

Importance: Optimal blood pressure (BP) management after successful endovascular therapy for acute ischemic stroke remains uncertain, as intensive lowering has shown no benefit or potential harm in prior trials. Objective: To determine whether a reperfusion-guided systolic BP control strategy improves functional outcomes compared with guideline-recommended management after successful endovascular therapy for acute ischemic stroke. Design, Setting, and Participants: This investigator-initiated, multicenter, prospective, randomized, open-label clinical trial with blinded end point assessment was conducted among adults with acute ischemic stroke due to anterior circulation large-vessel occlusion who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score ≥2b) after endovascular therapy at 11 comprehensive stroke centers in Spain between June 14, 2021, and October 1, 2025, with 90-day follow-up. Data analysis was conducted from February 1 to March 12, 2026. Interventions: Participants were randomly assigned (1:1) to a reperfusion-guided systolic BP strategy (140-160 mm Hg for mTICI score of 2b; 100-140 mm Hg for mTICI score of 2c/3) or guideline-recommended management (systolic BP <180 mm Hg) for 72 hours using antihypertensive agents or vasopressors as needed. Main Outcomes and Measures: The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale score of 0 to 2 at 90 days, assessed in the intention-to-treat population. Of 446 enrolled patients, 440 were included in the intention-to-treat analysis (mean age, 75 years; 53% women); 6 were excluded due to withdrawal or consent withdrawal. Results: Among 440 patients (mean [SD] age, 75 [12] years; 233 [53.0%] women), 215 were assigned to the intervention group and 225 to the control group. At 90 days, 129 patients (60.0%) in the intervention group and 106 (47.1%) in the control group achieved a favorable functional outcome (absolute risk difference, 13.3%; 95% CI, 4.1%-22.6%; P = .005). Hemorrhagic transformation occurred in 48 patients (22.3%) in the intervention group and 71 (31.6%) in the control group (odds ratio, 0.62; 95% CI, 0.41-0.95). The rates of symptomatic intracranial hemorrhage (3.5% vs 3.9%) and 90-day mortality (15.4% vs 15.6%) did not differ between groups. Serious adverse events occurred in 34 patients (15.8%) in the intervention group and 27 (12.0%) in the control group. Conclusions and Relevance: In this randomized clinical trial, a reperfusion-guided BP strategy improved functional outcomes and reduced hemorrhagic transformation without increasing major safety events, supporting a tailored approach to postthrombectomy BP management. Trial Registration: ClinicalTrials.gov Identifier: NCT04892511.