What are the optimal blood pressure targets following mechanical thrombectomy (thrombectomy) for cerebral thrombosis?

From the Guidelines

Blood pressure management after thrombectomy should target systolic blood pressure (SBP) below 180 mmHg for most patients, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The optimal blood pressure targets following mechanical thrombectomy for cerebral thrombosis are crucial to balance the risks of hemorrhagic transformation against the need for adequate cerebral perfusion in potentially ischemic penumbra.

• The 2024 ESC guidelines suggest that patients undergoing treatment with mechanical thrombectomy should have their blood pressure lowered to <180/105 mmHg prior to thrombectomy and maintained over the next 24 hours 1.
• The 2018 guidelines for the early management of patients with acute ischemic stroke also recommend maintaining blood pressure at a level ≤180/105 mmHg during and for 24 hours after the procedure 2.
• First-line medications for blood pressure management include intravenous labetalol, nicardipine, or clevidipine, which should be titrated as needed to achieve the target blood pressure.
• Blood pressure should be monitored frequently, typically every 15 minutes for the first 2 hours, then every 30 minutes for 6 hours, and hourly thereafter if stable.
• After 24-48 hours, gradual transition to oral antihypertensives is appropriate, considering the patient's baseline blood pressure, extent of reperfusion, and presence of intracranial stenosis, which might require higher targets to maintain cerebral perfusion. Key considerations in blood pressure management after thrombectomy include:
• The risk of reperfusion injury and intracranial hemorrhage, which requires proactive management of severe hypertension 1.
• The importance of individualization, considering the patient's baseline blood pressure, extent of reperfusion, and presence of intracranial stenosis 2, 1.
• The need for frequent blood pressure monitoring and titration of medications to achieve the target blood pressure.

From the Research

Optimal Blood Pressure Targets Following Mechanical Thrombectomy

The optimal blood pressure targets following mechanical thrombectomy for cerebral thrombosis are not well established. However, several studies provide some guidance on this issue:

• Before thrombectomy, the guidelines recommend a blood pressure < 185/110 mmHg, though patients with even lower systolic blood pressures may have better outcomes 3.
• During and after thrombectomy, the guidelines recommend a blood pressure < 180/105 mmHg 3.
• Some studies suggest that during thrombectomy, the primary goal should be to prevent significant low blood pressure, with a target systolic blood pressure > 140 mmHg or mean arterial pressure (MAP) > 70 mmHg 3.
• After thrombectomy, the primary goal should be to prevent high blood pressure, with a target systolic blood pressure < 160 mmHg or MAP < 90 mmHg 3.
• A prospective observational study found that moderate blood pressure control (< 160/90) was a predictor of improved 3-month mortality, and that a 10 mmHg increase in systolic blood pressure was associated with lower odds of having a favorable 3-month functional independence and higher rates of 3-month mortality 4.
• A survey of StrokeNet institutions found that the majority of institutions target systolic blood pressure during the first 24 hours post-thrombectomy, with most institutions targeting values of systolic blood pressure lower than 180 mmHg 5.
• A retrospective study found that maximum systolic blood pressure within 24 hours after thrombectomy was independently correlated with worse 90-day functional status and hemorrhagic complications 6.
• A randomized controlled trial (IDENTIFY) is currently underway to explore the efficacy and safety of early intensive blood pressure management strategies after thrombectomy, with a target blood pressure of < 130 mmHg in the intensive management group and < 180 mmHg in the standard management group 7.

Blood Pressure Management Strategies

Different blood pressure management strategies are being used in clinical practice, including:

• Permissive hypertension, with a target blood pressure < 220/120 mmHg or < 180/105 mmHg 3, 4.
• Moderate blood pressure control, with a target blood pressure < 160/90 mmHg 4.
• Intensive blood pressure management, with a target blood pressure < 130 mmHg 7.
• Standard blood pressure management, with a target blood pressure < 180 mmHg 7.

Future Research Directions

Further research is needed to determine the optimal blood pressure targets and management strategies following mechanical thrombectomy for cerebral thrombosis. Large, randomized-controlled studies are needed to address factors such as baseline blood pressure, timing and degree of revascularization, status of collaterals, and estimated risk of reperfusion injury 3.