More Intensive Versus Conservative Blood Pressure Lowering after Endovascular Therapy in Stroke: a meta-analysis of randomized controlled trials

Background The optimum systolic blood pressure after endovascular thrombectomy for acute ischemic stroke is uncertain. We aimed to perform an updated meta-analysis of randomized controlled trials to evaluate the safety and efficacy of more intensive blood pressure management as compared to less intensive blood pressure management. Methods We searched various electronic databases including Embase, MEDLINE (via PubMed), and CENTRAL to retrieve relevant randomized controlled trials (RCTs) on the clinical effects of more intensive blood pressure management after endovascular thrombectomy as compared to the less intensive management. We assessed the risk of bias using the revised Cochrane “Risk of bias” tool for randomized trials (RoB 2.0), calculated odds ratio (OR) with 95% confidence intervals (CI) for dichotomous outcomes. Results Our meta-analysis included 4 RCTs with a total of 1560 patients. According to our analysis, more intensive blood pressure management (<140 mmHg) was associated with a statistically significant decrease in the number of patients showing functional independence (modified Rankin scale mRS score = 0-2) at 90 days (OR 0.69; CI = 0.51-0.94; I² = 44%). Regarding 90-day mortality, our pooled results from three RCTs showed no statistically significant difference between the more intensive blood pressure management group and the less intensive blood pressure management group (140-180 mmHg) (OR 1.21; CI = 0.89-1.65; I² = 0%). There was no statistically significant difference between the two groups regarding the incidence of intracerebral hemorrhage (ICH) (OR 1.09; CI = 0.85-1.39; I² = 0%) and the incidence of symptomatic intracerebral hemorrhage (sICH) (OR 1.11; CI = 0.75-1.65; I² = 0%). Conclusion According to our meta-analysis, the intensive blood pressure lowering group was associated with a lower number of patients showing functional independence at 90 days We found no benefit of the intensive lowering of blood pressure on mortality rates and incidence of intracerebral hemorrhage as compared to the conservative BP management. Future large-scale trials should focus on other interventions to improve prognosis in these patients.