BP THROMBECTOMY METANALYSIS
(2026)Objective
To synthesize evidence from randomized controlled trials comparing intensive versus standard blood pressure control following mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion, in order to inform clinical decision-making.
Study Summary
• Intensive BP control increased all-cause mortality at 90 days: OR 1.21 (95% CI, 1.05–1.40)
• Intensive BP control more than doubled the risk of hypotensive episodes: OR 2.49 (95% CI, 1.56–3.96)
• No significant difference in excellent functional outcome (mRS 0–1 at 90 days): OR 0.91 (95% CI, 0.67–1.23), P=0.44
• No significant difference in symptomatic intracranial hemorrhage: OR 1.19 (95% CI, 0.89–1.61)
Intervention
Intensive blood pressure control (targeting SBP <130–140 mmHg) versus standard BP control following mechanical thrombectomy for acute ischemic stroke
Inclusion Criteria
Randomized controlled trials enrolling patients with acute ischemic stroke from large vessel occlusion treated with mechanical thrombectomy, comparing intensive versus standard post-procedural BP control, and reporting at least one relevant outcome
Study Design
Arms: Intensive BP control — SBP target <130–140 mmHg (n=944) vs Standard BP control — SBP ≤180/105 mmHg (n=958)
Patients per Arm: 944 intensive, 958 standard (total N=1902 across 6 RCTs)
Outcome
• All-cause mortality higher with intensive BP: OR 1.21 (95% CI, 1.05–1.40)
• Hypotensive episodes markedly increased with intensive BP: OR 2.49 (95% CI, 1.56–3.96)
• Excellent functional outcome (mRS 0–1) and symptomatic intracranial hemorrhage rates did not differ significantly between groups
Bottom Line
Intensive post-thrombectomy blood pressure lowering (targeting SBP <130–140 mmHg) does not improve and may worsen outcomes, with significantly reduced good functional recovery, higher all-cause mortality, and markedly increased hypotensive episodes compared to standard management; clinicians should avoid aggressive BP reduction after successful recanalization.
Major Points
- Meta-analysis of 6 RCTs encompassing 1902 patients demonstrates intensive BP control (SBP <130–140 mmHg) after thrombectomy does not improve functional outcomes
- Intensive BP control significantly reduced the likelihood of good functional outcome (mRS 0–2 at 90 days): OR 0.70 (95% CI, 0.54–0.91) — a 30% relative reduction in odds
- All-cause mortality at 90 days was significantly higher with intensive BP control: OR 1.21 (95% CI, 1.05–1.40)
- Hypotensive episodes were more than twice as common with intensive BP control: OR 2.49 (95% CI, 1.56–3.96)
- No significant difference in excellent functional outcome (mRS 0–1 at 90 days): OR 0.91 (95% CI, 0.67–1.23), P=0.44, I²=23%
- No significant difference in symptomatic intracranial hemorrhage: OR 1.19 (95% CI, 0.89–1.61)
- Evidence certainty was high for functional outcomes and hypotensive episodes; moderate for all-cause mortality and symptomatic intracranial hemorrhage
- Current AHA/ASA guidelines recommending SBP ≤180/105 mmHg for ≥24 hours after recanalization are supported by this evidence
- Postthrombectomy BP management should be approached cautiously — aggressive SBP reduction carries measurable harm without functional benefit
Study Design
- Study Type
- Systematic review and meta-analysis of randomized controlled trials
- Randomization
- Yes
- Blinding
- Varied across included trials
- Sample Size
- 1902
- Follow-up
- 90 days
- Countries
- France, China, United States, South Korea, Canada
Primary Outcome
Definition: Excellent functional outcome (mRS 0–1 at 90 days) and good functional outcome (mRS 0–2 at 90 days)
| Control | Intervention | HR/OR | P-value |
|---|---|---|---|
| Reference (standard BP control) | Intensive BP control | 0.7 (0.54–0.91 (good functional outcome); 0.67–1.23 (excellent functional outcome)) | P=0.44 for excellent functional outcome (mRS 0–1); significant for good functional outcome (mRS 0–2) |
Limitations & Criticisms
- Only 6 RCTs included — insufficient number for funnel plot analysis or formal publication bias assessment
- Heterogeneity in BP targets across trials (SBP <130 vs <140 mmHg) may limit interpretability of pooled estimates
- Blinding varied across included trials, introducing potential performance and detection bias
- Baseline characteristics differed across trials conducted in different countries and healthcare systems
- The text is truncated; full sensitivity analysis results and all subgroup data not available in the provided source
Citation
Hashmi TM, et al. Intensive Versus Standard Blood Pressure Control After Endovascular Thrombectomy in Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc. 2026;15:e045503.