Abstract Background and aims Optimal blood pressure (BP) control after reperfusion for acute ischemic stroke is critical yet controversial. We aimed to compare an intensive (SBP 160 mmHg) versus standard (SBP 161-185 mmHg) BP strategy after intravenous thrombolysis (TLT) and assess the prognostic value of non-invasive cerebral oximetry. Methods In this single-center trial, we randomized 64 adults with AIS undergoing TLT to intensive (n=30) or standard (n=34) BP control for 24 hours. Primary endpoints were 90-day mortality and good functional outcome (modified Rankin Scale mRS 0-2). A secondary analysis evaluated the interhemispheric difference in regional cerebral oxygen saturation (ΔrSO2) as an outcome predictor. Results Mean 24-hour SBP was 8.9 mmHg lower in the intensive group (145.2±10.8 vs. 154.1±10.3 mmHg; p0.001). Neither 90-day mortality (OR 1.1, 95% CI 0.3–4.8) nor good functional outcome (OR 1.3, 95% CI 0.4–3.7) differed between groups. No symptomatic hemorrhages occurred, but any intracranial hemorrhage was numerically higher in the intensive arm (27.3% vs. 13.9%; p=0.27). An interhemispheric ΔrSO2 4% at 24 hours independently predicted good functional outcome (adj. OR 12, 95% CI 1.6–93.7; p=0.017). Conclusions An intensive BP-lowering strategy (SBP 160 mmHg) after TLT did not improve 90-day outcomes, reinforcing the safety of current guidelines (target SBP 185 mmHg). While this intervention failed, non-invasive cerebral oximetry emerges as a strong prognostic tool. A smaller interhemispheric oxygenation difference (ΔrSO2 4%) independently predicted superior recovery, identifying patients poised for favorable outcomes post-reperfusion. Conflict of interest Kostiantyn Stepanchenko and Alla Zhidkova nothing to disclose
Stepanchenko et al. (2026) studied this question.