Review Article| Volume 418, 117140, November 15, 2020

Blood pressure management after mechanical thrombectomy in stroke patients

Published:September 13, 2020DOI:


      • Optimal blood pressure management in acute phase after thrombectomy may improve the outcomes.
      • Higher blood pressure variability has been associated with poor outcomes.
      • A target Systolic blood pressure < 160 in the first 24 h after thrombectomy may improve the outcomes.


      Endovascular treatment of acute ischemic stroke (AIS) and mechanical thrombectomy (MT) is proven as a safe and effective novel treatment for emergent large vessel occlusion in the anterior cerebral circulation. However, there are still many unanswered questions on peri and post-procedural management including blood pressure (BP) control. The current guidelines recommend maintaining BP <180/105 mmHg in the first 24 h after MT. However, recent studies suggest that maintaining BP levels at lower levels in the first 24 h after successful revascularization have been associated with favorable functional outcome, reduced mortality rate, and hemorrhagic complications. Not only absolute BP but also its variation in the first 24 h after MT have been associated with neurological outcomes. Evidence on the effect of BP variability (BPV) after MT in AIS even though limited, it does indicate the association of the higher BPV in the first 24 h after MT and poor functional outcomes in AIS. In this review, we will discuss the current literature on BP management in the first 24 h after MT and the impact of BPV in the first 24 h after MT.


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        • Wartenberg K.E.
        • Mayer S.A.
        Determining the optimal target blood pressure after thrombectomy: high or low?.
        Neurology. 2017; 89: 528-529
        • Choi K.H.
        • Kim J.M.
        • Kim J.H.
        • et al.
        Optimal blood pressure after reperfusion therapy in patients with acute ischemic stroke.
        Sci. Rep. 2019; 9: 5681
        • Buratti L.
        • Cagnetti C.
        • Balucani C.
        • et al.
        Blood pressure variability and stroke outcome in patients with internal carotid artery occlusion.
        J. Neurol. Sci. 2014; 339: 164-168
        • Manning L.S.
        • Rothwell P.M.
        • Potter J.F.
        • Robinson T.G.
        Prognostic significance of short-term blood pressure variability in acute stroke: systematic review.
        Stroke. 2015; 46: 2482-2490
        • Bosel J.
        Optimal blood pressure for stroke thrombectomy: high time for prospective data!.
        Stroke. 2019; 50: 2648-2649
        • Qureshi A.I.
        Acute hypertensive response in patients with stroke: pathophysiology and management.
        Circulation. 2008; 118: 176-187
        • Willmot M.
        • Leonardi-Bee J.
        • Bath P.M.
        High blood pressure in acute stroke and subsequent outcome: a systematic review.
        Hypertension. 2004; 43: 18-24
        • Powers W.J.
        • Rabinstein A.A.
        • Ackerson T.
        • et al.
        Guidelines for the early Management of Patients with Acute Ischemic Stroke: 2019 update to the 2018 guidelines for the early Management of Acute Ischemic Stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2019; 50: e344-e418
        • Damani R.
        A brief history of acute stroke care.
        Aging. 2018; 10: 1797-1798
        • Emberson J.
        • Lees K.R.
        • Lyden P.
        • et al.
        Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials.
        Lancet. 2014; 384: 1929-1935
        • Goyal M.
        • Menon B.K.
        • van Zwam W.H.
        • et al.
        Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.
        Lancet. 2016; 387: 1723-1731
        • Nogueira R.G.
        • Jadhav A.P.
        • Haussen D.C.
        • et al.
        Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.
        N. Engl. J. Med. 2018; 378: 11-21
        • Albers G.W.
        • Marks M.P.
        • Kemp S.
        • et al.
        Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.
        N. Engl. J. Med. 2018; 378: 708-718
        • Raymond S.
        • Rost N.S.
        • Schaefer P.W.
        • et al.
        Patient selection for mechanical thrombectomy in posterior circulation emergent large-vessel occlusion.
        Interv. Neuroradiol. 2018; 24: 309-316
        • Leslie-Mazwi T.
        • Chen M.
        • Yi J.
        • et al.
        Post-thrombectomy management of the ELVO patient: guidelines from the society of neurointerventional surgery.
        J. Neurointerventional Surg. 2017; 9: 1258-1266
        • Gauberti M.
        • Lapergue B.
        • Martinez de Lizarrondo S.
        • et al.
        Ischemia-reperfusion injury after endovascular thrombectomy for ischemic stroke.
        Stroke. 2018; 49: 3071-3074
        • Mistry E.A.
        • Mistry A.M.
        • Nakawah M.O.
        • et al.
        Systolic blood pressure within 24 hours after thrombectomy for acute ischemic stroke correlates with outcome.
        J. Am. Heart Assoc. 2017; 6
        • Hillis A.E.
        • Ulatowski J.A.
        • Barker P.B.
        • et al.
        A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and subacute stroke.
        Cerebrovasc. Dis. 2003; 16: 236-246
        • Rordorf G.
        • Koroshetz W.J.
        • Ezzeddine M.A.
        • Segal A.Z.
        • Buonanno F.S.
        A pilot study of drug-induced hypertension for treatment of acute stroke.
        Neurology. 2001; 56: 1210-1213
        • Bösel J.
        Blood pressure control for acute severe ischemic and hemorrhagic stroke.
        Curr. Opin. Crit. Care. 2017; 23: 81-86
        • Jafari M.
        • Damani R.
        Blood pressure variability and outcome after acute intracerebral hemorrhage.
        J. Neurol. Sci. 2020; 413: 116766
        • Rose J.C.
        • Mayer S.A.
        Optimizing blood pressure in neurological emergencies.
        Neurocrit. Care. 2006; 4: 98
        • Robinson T.G.
        • James M.
        • Youde J.
        • Panerai R.
        • Potter J.
        Cardiac baroreceptor sensitivity is impaired after acute stroke.
        Stroke. 1997; 28: 1671-1676
        • De Raedt S.
        • De Vos A.
        • De Keyser J.
        Autonomic dysfunction in acute ischemic stroke: an underexplored therapeutic area?.
        J. Neurol. Sci. 2015; 348: 24-34
        • Tang Y.
        • Sorenson J.
        • Lanspa M.
        • Grissom C.K.
        • Mathews V.J.
        • Brown S.M.
        Systolic blood pressure variability in patients with early severe sepsis or septic shock: a prospective cohort study.
        BMC Anesthesiol. 2017; 17: 82
        • Huston J.M.
        • Tracey K.J.
        The pulse of inflammation: heart rate variability, the cholinergic anti-inflammatory pathway and implications for therapy.
        J. Intern. Med. 2011; 269: 45-53
        • Goyal M.
        • Demchuk A.M.
        • Menon B.K.
        • et al.
        Randomized assessment of rapid endovascular treatment of ischemic stroke.
        N. Engl. J. Med. 2015; 372: 1019-1030
        • Talke P.O.
        • Sharma D.
        • Heyer E.J.
        • Bergese S.D.
        • Blackham K.A.
        • Stevens R.D.
        Society for neuroscience in anesthesiology and critical care expert consensus statement: anesthetic management of endovascular treatment for acute ischemic stroke*: endorsed by the society of neurointerventional surgery and the neurocritical care society.
        J. Neurosurg. Anesthesiol. 2014; 26: 95-108
        • Martins A.I.
        • Sargento-Freitas J.
        • Silva F.
        • et al.
        Recanalization modulates association between blood pressure and functional outcome in acute ischemic stroke.
        Stroke. 2016; 47: 1571-1576
        • Goyal N.
        • Tsivgoulis G.
        • Pandhi A.
        • et al.
        Blood pressure levels post mechanical thrombectomy and outcomes in non-recanalized large vessel occlusion patients.
        J. Neurointerventional Surg. 2018; 10: 925-931
        • Goyal N.
        • Tsivgoulis G.
        • Pandhi A.
        • et al.
        Blood pressure levels post mechanical thrombectomy and outcomes in large vessel occlusion strokes.
        Neurology. 2017; 89: 540-547
        • Anadani M.
        • Orabi M.Y.
        • Alawieh A.
        • et al.
        Blood pressure and outcome after mechanical thrombectomy with successful revascularization.
        Stroke. 2019; 50: 2448-2454
        • Matusevicius M.
        • Cooray C.
        • Bottai M.
        • et al.
        Blood Pressure After Endovascular Thrombectomy: Modeling for Outcomes Based on Recanalization Status.
        Stroke. 2020; 51: 519-525
        • Mistry E.A.
        • Sucharew H.
        • Mistry A.M.
        • et al.
        Blood pressure after endovascular therapy for ischemic stroke (BEST): a multicenter prospective cohort study.
        Stroke. 2019; 50: 3449-3455
        • McCarthy D.J.
        • Ayodele M.
        • Luther E.
        • et al.
        Prolonged heightened blood pressure following mechanical thrombectomy for acute stroke is associated with worse outcomes.
        Neurocrit. Care. 2020; 32: 198-205
        • Matusevicius M.
        • Cooray C.
        • Bottai M.
        • et al.
        Blood pressure after endovascular thrombectomy: modeling for outcomes based on recanalization status.
        Stroke. 2020; 51: 519-525
        • Malhotra K.
        • Goyal N.
        • Katsanos A.H.
        • et al.
        Association of blood pressure with outcomes in acute stroke thrombectomy.
        Hypertension. 2020; 75: 730-739
        • Bennett A.E.
        • Wilder M.J.
        • McNally J.S.
        • et al.
        Increased blood pressure variability after endovascular thrombectomy for acute stroke is associated with worse clinical outcome.
        J. Neurointerventional Surg. 2018; 10: 823-827
        • Mistry E.A.
        • Mehta T.
        • Mistry A.
        • et al.
        Blood Pressure Variability and Neurologic Outcome After Endovascular Thrombectomy: A Secondary Analysis of the BEST Study.
        Stroke. 2020; 51: 511-518
        • Endo K.
        • Kario K.
        • Koga M.
        • et al.
        Impact of early blood pressure variability on stroke outcomes after thrombolysis: the SAMURAI rt-PA Registry.
        Stroke. 2013; 44: 816-818
        • Webb A.J.
        • Fischer U.
        • Mehta Z.
        • Rothwell P.M.
        Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis.
        Lancet. 2010; 375: 906-915