Dynamic systolic blood pressure profiles across early time windows and clinical outcomes after intravenous thrombolysis in acute ischemic stroke: a prospective cohort study

Background Optimal blood pressure management after intravenous thrombolysis in acute ischemic stroke (AIS) remains uncertain. To assess peri-thrombolysis systolic blood pressure (SBP) dynamics and to examine the associations of mean SBP, SBP variability, and SBP reduction magnitude with 90-day functional outcome and 24-h intracranial hemorrhage (ICH) after intravenous thrombolysis in AIS. Methods In this single-center prospective observational cohort study, 340 consecutive patients with AIS treated with intravenous thrombolysis were included. SBP was summarized across predefined time windows: pre-thrombolysis, during thrombolysis, and 0–2 h, 2–6 h, 6–12 h, and 12–24 h after thrombolysis. The primary outcome was unfavorable 90-day functional outcome, defined as modified Rankin scale score 3–6. The secondary outcome was 24-h ICH. Results Of the 340 patients included, 126 (37.06%) had an unfavorable 90-day outcome. After adjustment, each 10-mmHg increase in mean SBP was associated with higher odds of unfavorable outcome in the pre-thrombolysis period (adjusted OR [aOR] 1.21, 95% CI 1.03–1.43), during thrombolysis (aOR 1.18, 95% CI 1.01–1.39), at 0–2 h (aOR 1.25, 95% CI 1.06–1.49), at 2–6 h (aOR 1.23, 95% CI 1.04–1.46), and at 6–12 h (aOR 1.19, 95% CI 1.01–1.41). In categorical analysis, an early mean SBP of 120–140 mmHg was associated with lower risk of unfavorable outcome at 0–2 h (aOR 0.51, 95% CI 0.27–0.96), whereas SBP ≥ 160 mmHg was associated with increased risk at both 0–2 h (aOR 2.34, 95% CI 1.23–4.47) and 2–6 h (aOR 3.12, 95% CI 1.45–6.72). Greater early SBP reduction was associated with lower 24-h ICH risk, particularly at 0–2 h (absolute reduction: aOR 0.91, 95% CI 0.85–0.97; relative reduction: aOR 0.84, 95% CI 0.75–0.95) and 2–6 h (absolute reduction: aOR 0.89, 95% CI 0.83–0.95; relative reduction: aOR 0.81, 95% CI 0.72–0.91). Conclusions Higher mean SBP across early time windows, particularly within the first 6 h after thrombolysis, was independently associated with an unfavorable 90-day outcome.