Blood pressure control may be the key to optimizing stroke treatment after thrombectomy

Blood pressure management after thrombectomy for acute ischemic stroke may require a change in approach. The HOPE clinical trial-short for Hemodynamic Optimization of Cerebral Perfusion after Endovascular Therapy-led by the Sant Pau Research Institute (IR Sant Pau), has shown that adapting blood pressure targets to the degree of cerebral reperfusion significantly improves patients' functional recovery without increasing the risk of complications.

Until now, we have applied fairly uniform strategies after thrombectomy, but probably not all patients need the same approach. Our results suggest that adjusting blood pressure according to the degree of reperfusion can have a direct impact on recovery."

Dr. Pol Camps-Renom, head of the Cerebrovascular Diseases Research Group at IR Sant Pau and one of the study coordinators

The findings, presented during a plenary session at the annual European Stroke Organisation conference-the leading European scientific society dedicated to stroke-and now published in JAMA Neurology position this work among the most important recent contributions in the stroke field. They have the potential to guide new hemodynamic management strategies after thrombectomy.

Reopening the artery does not always translate into recovery

Mechanical thrombectomy has been a major advance in the treatment of large-vessel occlusion stroke because it can restore blood flow in previously blocked arteries. However, a well-known paradox remains in clinical practice: despite successful angiographic reperfusion, a substantial proportion of patients-around half-do not achieve satisfactory functional recovery in the medium term.

This phenomenon, known as "clinically ineffective reperfusion," reflects the fact that reopening the vessel does not always result in effective restoration of cerebral perfusion at the tissue level. Mechanisms involved include reperfusion injury, microcirculatory dysfunction, loss of cerebral autoregulation, and hemorrhagic transformation, all of which can compromise brain tissue viability even after a technically successful intervention.

"Many times we can reopen the artery, but the brain tissue does not respond as expected," explains Dr. Pol Camps-Renom. "The reason is that microvascular perfusion and autoregulatory mechanisms may be impaired, and this is where factors such as blood pressure become critical."

As a result, blood pressure control during the hours following thrombectomy has become a key component of clinical management because it directly influences the balance between maintaining adequate perfusion and avoiding hemorrhagic complications. However, the evidence available so far has been limited and, at times, contradictory. Previous trials based on uniform intensive blood pressure reduction strategies have not demonstrated consistent benefits and have even suggested possible adverse effects.

An individualized approach based on reperfusion physiology

The HOPE trial introduces a different approach based on the concept that hemodynamic management should be adapted to each patient's physiological condition after thrombectomy. The study included 440 patients treated at 11 Spanish hospitals, who were randomly assigned either to a conventional strategy or to blood pressure management tailored to the degree of reperfusion achieved.

Unlike previous trials, HOPE implemented a differentiated strategy according to the final angiographic result. Patients with near-complete or complete reperfusion were treated with lower blood pressure targets to reduce the risk of reperfusion injury, whereas patients with incomplete reperfusion maintained higher blood pressure levels to preserve cerebral perfusion.

This approach recognizes that the brain may be in extremely diverse hemodynamic states, in which both excessively high blood pressure and overly aggressive reductions can be harmful. For this reason, the protocol included close monitoring during the first 72 hours, with dynamic treatment adjustments.

Better functional recovery without increased complications

This strategy resulted in a significant and consistent improvement in clinical outcomes. At 90 days, 60.0% of patients in the intervention group achieved functional independence, compared with 47.1% in the control group, representing an absolute difference of 13.3 percentage points, a clinically meaningful improvement. In addition, the overall analysis showed a favorable trend toward better levels of recovery, reinforcing the consistency of the benefit.

In terms of safety, the strategy was associated with a lower incidence of hemorrhagic transformation, without increasing mortality or serious complications, confirming a favorable balance between efficacy and safety. "We have shown that it is possible to improve patient recovery without adding risk," adds Dr. Joan Martí-Fàbregas, another investigator involved in the study. "This balance between efficacy and safety is probably one of the most relevant aspects of the findings."

Toward a paradigm shift in post-stroke management

The results of the HOPE trial point toward a more individualized model for blood pressure control after thrombectomy. In a setting where previous trials had produced neutral or unfavorable results, this study introduces a physiology-based approach that can optimize the balance between perfusion and hemorrhagic risk.

Beyond its findings, HOPE provides key elements for the design of future studies, including the stratification of therapeutic targets and prolonged hemodynamic monitoring. The study also reinforces the idea that stroke treatment does not end with recanalization but continues during the hours that follow. "Rather than applying rigid targets, the key is to better understand each patient's physiology," concludes Dr. Camps-Renom.

Although the trial was stopped before reaching the planned sample size, its results demonstrate a clinically meaningful effect size. Nevertheless, additional studies will be required to confirm these findings before they can be broadly incorporated into routine clinical practice.

Overall, the HOPE trial positions blood pressure control as a key component in optimizing stroke treatment after thrombectomy and opens the door to more precise strategies tailored to individual patients.