What is the ideal blood pressure (BP) management strategy for a patient undergoing thrombectomy?

Blood Pressure Management During Thrombectomy

Maintain blood pressure <185/110 mm Hg before thrombectomy (or <180 mm Hg systolic if the patient received IV thrombolytics), then keep BP <180/105 mm Hg during and for 24 hours after the procedure, with tighter control to <140 mm Hg systolic if successful reperfusion is achieved. 1, 2

Pre-Procedure Blood Pressure Targets

For patients NOT receiving IV thrombolytics:

• Target BP <185/110 mm Hg before starting mechanical thrombectomy 1
• This threshold balances adequate cerebral perfusion to the ischemic penumbra while minimizing hemorrhagic risk 1

For patients who RECEIVED IV thrombolytics:

• Target systolic BP <180 mm Hg before thrombectomy 1
• This stricter threshold reduces hemorrhagic transformation risk in thrombolytic-treated patients 1

During the Procedure

Avoid hypotension aggressively:

• The primary goal during thrombectomy is preventing low blood pressure, which compromises collateral perfusion and extends infarct 3
• Some evidence suggests targeting systolic BP >140 mm Hg or mean arterial pressure >70 mm Hg during the procedure to maintain adequate cerebral perfusion 3
• Monitor vital signs every 5 minutes during the procedure 1

Upper limit:

• Maintain BP <180/105 mm Hg to prevent hemorrhagic transformation once recanalization occurs 1, 2

Post-Procedure Management (First 24 Hours)

The approach differs based on reperfusion status:

If Successful Reperfusion Achieved:

• Target systolic BP <140 mm Hg for the first 24 hours 2
• This tighter control prevents reperfusion injury and hemorrhagic transformation in successfully recanalized vessels 2
• The DAWN trial protocol specifically supports this lower target after successful thrombectomy 2

If Unsuccessful Reperfusion:

• Maintain BP <180/105 mm Hg but avoid aggressive lowering 2, 4
• Permissive hypertension up to 220/120 mm Hg may be acceptable to maintain collateral flow to the ischemic penumbra 4
• Do not treat BP aggressively when the vessel remains occluded, as this compromises cerebral perfusion 2

Pharmacological Agents

First-line medications:

• Labetalol: 10-20 mg IV over 1-2 minutes, may repeat once 1, 2
• Nicardipine: 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h 1
• Clevidipine: 1-2 mg/h IV, titrate by doubling dose every 2-5 minutes until desired BP reached, maximum 21 mg/h 1

Agent selection rationale:

• Choose agents that allow precise titration and avoid precipitous drops 2, 4
• IV beta-blockers like metoprolol in low doses are also acceptable 2

Monitoring Frequency

Post-thrombectomy vital sign monitoring schedule:

• Every 15 minutes for 2 hours 1
• Every 30 minutes for 6 hours 1
• Every 1 hour for 16 hours 1

Critical Pitfalls to Avoid

Excessive BP drops:

• Never drop systolic BP by >70 mm Hg within 1 hour 2, 4, 5
• Rapid drops cause acute renal injury and early neurological deterioration 2, 4

Treating BP when vessel remains occluded:

• Avoid aggressive BP lowering if thrombectomy was unsuccessful, as this compromises collateral perfusion to the penumbra 2, 4

Ignoring reperfusion status:

• Successful reperfusion requires tighter BP control (<140 mm Hg systolic) to prevent hemorrhagic transformation 2
• Failed reperfusion requires permissive hypertension to maintain collateral flow 2, 4

Hypotension during procedure:

• Intraprocedural hypotension is associated with worse outcomes 3
• Maintain adequate perfusion pressure throughout the procedure, prioritizing prevention of low BP over aggressive treatment of high BP 3

After 72 Hours

• If patient remains stable and hypertensive (≥140/90 mm Hg), initiate or restart antihypertensive medications for long-term secondary prevention 2, 4