Relationship between blood pressure level with prognosis of acute ischemic stroke patients treated with intravenous thrombolysis: a systematic review and meta-analysis

Blood pressure (BP) management after intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) remains challenging, and evidence on how BP levels relate to prognosis is inconsistent. We performed a systematic review and meta-analysis to evaluate associations between pre-/post-treatment BP levels and clinical outcomes after IVT. We conducted this systematic review and meta-analysis in accordance with PRISMA. PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to January 8, 2026, restricted to English-language published clinical studies. Adults with AIS treated with intravenous alteplase were eligible. Pre-treatment BP was defined as the measurement closest to IVT initiation; post-treatment BP preferentially referred to the mean BP within 2–4 h after completion of alteplase infusion (or 24–72 h when unavailable). Outcomes included 3-month functional outcome (favorable modified Rankin Scale (mRS) 0–2 vs. unfavorable mRS 3–6), symptomatic intracranial hemorrhage (sICH; study-specific definitions), and 3-month mortality. Mean differences (MDs) and odds ratios (ORs) were pooled using fixed- or random-effects models based on heterogeneity. Thirty-four studies were included. For functional outcome, 5,582 patients had favorable outcome and 5,179 had unfavorable outcome; the weighted mean pre-treatment SBP was 150.0 vs. 151.5 mmHg, respectively, and the pooled MD indicated lower pre-treatment SBP in the favorable group (MD = − 5.58 mmHg, 95% CI − 9.04 to − 2.12; I²=79%). For post-treatment SBP, 4,963 vs. 4,467 patients were included; the weighted mean SBP was 144.9 vs. 149.0 mmHg, and the pooled MD was − 4.09 mmHg (95% CI − 4.98 to − 3.20; I²=0%). For sICH, 279/12,362 (2.26%) patients developed sICH; the weighted mean pre-treatment SBP was 151.6 vs. 157.9 mmHg (no sICH vs. sICH), and the pooled MD was − 5.89 mmHg (95% CI − 8.26 to − 3.51; I²=0%). For post-treatment SBP, 182/10,541 (1.73%) patients developed sICH; the weighted mean SBP was 147.2 vs. 159.7 mmHg, and the pooled MD was − 11.71 mmHg (95% CI − 15.05 to − 8.37; I²=45%). Evidence for mortality and BP variability was limited. Higher SBP before and after IVT was associated with poorer 3-month functional outcome and with sICH. Further prospective studies with standardized BP ascertainment and outcome definitions are needed.