Poorer Outcomes With Blood Pressure Lowering in Severe White Matter Disease After Thrombectomy

BACKGROUND: Intensive blood pressure (BP) management after successful endovascular thrombectomy (EVT) worsens outcomes in acute ischemic stroke. White matter hyperintensity (WMH), associated with impaired cerebral autoregulation, is associated with poor outcomes after EVT; however, its role in modifying BP management effects remains unclear. We investigated whether WMH severity modifies the effect of post-EVT BP management on outcomes. METHODS: This secondary analysis of the OPTIMAL-BP trial (Outcome in Patients Treated With Intra-arterial Thrombectomy–Optimal Blood Pressure Control; conducted at 19 South Korean stroke centers, 2020–2022) included patients with available Fluid-Attenuated Inversion Recovery images. The trial compared intensive (<140 mm Hg) versus conventional (140–180 mm Hg) systolic BP management for 24 hours post-EVT. WMH severity was assessed via the Fazekas scale (severe defined as a total score ≥3). The primary outcome was functional independence (modified Rankin Scale score, 0–2) at 3 months. Safety outcomes included symptomatic intracerebral hemorrhage within 36 hours and stroke-related death within 3 months. Multivariable logistic regression was used to estimate adjusted odds ratios and 95% CI, adjusting for age, sex, onset-to-reperfusion time, intravenous thrombolysis, complete reperfusion, and baseline stroke severity. RESULTS: Of 271 patients (median, 75.0 years; 59.0% men), 163 (60.1%) had severe WMH. In this group, intensive management was associated with a lower rate of functional independence compared with conventional management (29.9% versus 51.3%; adjusted odds ratio, 0.36 95% CI, 0.16–0.79; P =0.011). In contrast, no significant difference was observed in patients with mild WMH (55.8% versus 69.6%; adjusted odds ratio, 0.77 95% CI, 0.31–1.95; P =0.584). Symptomatic intracerebral hemorrhage and stroke-related death rates did not differ by BP management in either group. CONCLUSIONS: Intensive BP management post-EVT was associated with poorer functional outcomes, particularly in patients with severe WMH. WMH burden may modify BP control effects, supporting individualized BP targets based on WMH severity. REGISTRATION: URL: https://clinicaltrials.gov/study ; Unique identifier: NCT04205305.