Original Investigation 

Personalized Blood Pressure Targeting After Endovascular Therapy for Acute Ischemic Stroke: A Randomized Clinical Trial

Pol Camps-Renom, Marina Guasch-Jiménez, Juan Álvarez-Cienfuegos, et al

JAMA Neurol Published Online: June 8, 2026

doi: 10.1001/jamaneurol.2026.1706

Key Points

Question  Does a reperfusion-guided systolic blood pressure control strategy improve functional outcomes after successful endovascular therapy for acute ischemic stroke compared with guideline-recommended management?

Findings  In this multicenter randomized clinical trial including 440 patients, a higher proportion of patients in the intervention group achieved a favorable functional outcome at 90 days compared with the control group, and this difference was statistically significant. Hemorrhagic transformation occurred less frequently in the intervention group, while mortality and symptomatic intracranial hemorrhage did not differ significantly between groups.

Meaning  These findings suggest that reperfusion-guided blood pressure management may improve functional recovery without increasing safety risks after endovascular therapy.

Abstract

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