Effects of Blood Pressure Lowering in Patients Treated with Intravenous Thrombolysis Before Endovascular Thrombectomy

Background: The effects of blood pressure (BP) lowering in patients treated with intravenous tissue plasminogen activator (IV tPA) before endovascular thrombectomy (EVT) are unclear.

Aims: This study aims to investigate whether intensive and conventional BP management affects outcomes differently, depending on IV tPA administration before EVT.

Methods: In this subgroup analysis of the Outcome in Patients Treated with Intra-Arterial Thrombectomy-Optimal Blood Pressure Control (OPTIMAL-BP; ClinicalTrials.gov Identifier: NCT04205305) trial, patients were divided into groups based on IV tPA use before EVT. Clinical outcomes of intensive (systolic BP target < 140 mm Hg) or conventional BP management (systolic BP target 140-180 mm Hg) were compared among groups. The primary efficacy outcome was a favorable outcome at 3 months (modified Rankin Scale score of 0-2). Primary safety outcomes included symptomatic intracerebral hemorrhage (sICH) within 36 h and stroke-related death within 3 months.

Results: Among the 302 patients, the IV tPA group included 98 (32.5%) and the non-IV tPA group comprised 204 subjects (67.5%). In the IV tPA group, intensive BP management significantly lowered the favorable outcome rate (intensive, 27.3% vs. conventional, 51.9%; adjusted odds ratio [aOR], 0.36; 95% confidence interval [CI], 0.13-0.93;  = 0.04). In the non-IV tPA group, the risk difference rate of favorable outcome was not significantly different between intensive and conventional BP management (44.1% vs. 55.9%; aOR, 0.62; 95% CI, 0.31-1.22;  = 0.17). Notably, the proportion of malignant cerebral edema within 36 h in the IV tPA group was significantly higher in the intensive management group (18.2%) than in the conventional management group (1.9%; aOR, 10.72; 95% CI, 1.24-92.29;  = 0.03). sICH and mortality rates were not significantly different between intensive and conventional BP management in either study groups.

Conclusions: Intensive BP management worsens 3-month functional outcomes after successful EVT without reducing sICH among patients who received IV tPA before EVT, indicating that BP lowering in this population should be cautious.