Optimal Systolic Blood pressure control after thrombectomy in acute ischemic stroke-a systematic review and meta-analysis

Abstract Background and Objectives Although endovascular thrombectomy(EVT) is the standard of care for acute large vessel occlusions(LVO), optimal systolic blood pressure (SBP) control post procedure has remained elusive. Our study aimed to address the question of whether in adult patients of acute ischemic stroke(AIS) who undergo EVT does an intensive SBP control as compared to a less intensive SBP control/conventional control up to 24 hours post procedure lead to a good functional outcomes defined by modified Rankin score(mRS) of 0-2 at 90days. Methods This PRISMA guidelines were followed for this review. Databases(PubMed, SCOPUS, EMBASE, Google Scholar and Web of Science) were searched for English language articles using predefined search terms till Sep 15 2023. The inclusion criteria consisted of randomized controlled trials (RCTs) and observational studies(at least total 20patients) analysing intensive vs conventional SBP control in AIS due to LVO post-EVT up to 24hours. Studies without a separate comparison primary outcome data, comparing SBP control in AIS due to LVO treated only with IV thrombolysis (IVT) without EVT, case series and case reports were excluded. The primary outcome was the rate of functional independence defined by mRS 0-2 at 90days. Risk of bias was assessed using the New Castle Ottawa scale(NOS) for observational studies, and the revised Cochrane risk-of-bias 2 (ROB2) tool for RCTs. Results Twelve studies(n=5439 patients-eight observational and four RCTs) were included in the final analysis. The primary outcome was not significantly different between both the arms(RR:1.16;95%CI-0.98-1.37;p=0.08).There were no significant differences in the mortality at 90days(RR:0.83;95%CI-0.68-1.02;p=0.08) and the risk of symptomatic intracranial haemorrhage(RR:0.84;95%CI-0.61-1.16;p=0.29). Fewer patients required decompressive surgery in the intensive arm(RR-0.40; 95%CI-0.25-0.66; p=0.0003). A separate analysis for the primary outcome from pooled observational data favoured intensive control(RR-1.34;95%CI-1.20-1.48; p<0.00001) and data from RCTs favoured conventional control(RR-0.82;95%CI-0.72-0.93;p=0.003). Conclusion Neither intensive nor conventional SBP control resulted in better functional outcome in the combined analysis of all studies. Although, observational studies favoured intensive control, data from RCTs suggested conventional management as the preferred approach which could currently be a pragmatic strategy. Further ongoing RCTs using homogenous SBP cut-offs will provide more clarity on the ideal SBP target after EVT.