After successful thrombectomy, aggressive pressure lowering was the harmful choice

Design

Bayesian network meta-analysis of randomised trials with meta-regression

Population

eight randomised trials of systolic pressure targets after successful endovascular thrombectomy

Primary outcome

functional independence, with symptomatic intracranial haemorrhage and 90-day mortality as safety outcomes

Effect

target below 180 mmHg ranked highest (SUCRA 87.3%); below 140 mmHg OR 1.65 (1.03-2.54) and below 120 mmHg OR 1.75 (1.14-2.71) for worse outcome

Eight randomised trials of systolic blood pressure targets after successful endovascular thrombectomy were combined in a Bayesian network meta-analysis, with functional independence as the outcome and a meta-regression of achieved 24-hour mean pressure.

The permissive target ranked best. A ceiling below 180 mmHg had a surface under the cumulative ranking curve of 87.3%, while tighter targets did worse: below 140 mmHg carried an odds ratio of 1.65 (95% CI 1.03-2.54) and below 120 mmHg an odds ratio of 1.75 (1.14-2.71) for the unfavourable direction, at high certainty. Symptomatic intracranial haemorrhage and 90-day mortality did not differ between targets - so the harm from tight control is functional, not haemorrhagic. Within the observed 117 to 139 mmHg range, higher achieved pressure was associated with better outcome at group level.

The physiology is straightforward once stated: after recanalisation the penumbra is still dependent on collateral perfusion, and dropping systemic pressure hard removes the driving force keeping it alive. Five of six comparisons violated the proportional odds assumption, meaning the effect differs across disability levels and a single odds ratio understates the picture. The group-level meta-regression is ecological and should not be read as an individual dose-response. The usable instruction is conservative and clear: after successful recanalisation, treat an urge to normalise the blood pressure as the thing to resist.

• Avoid driving systolic pressure below 140 mmHg after successful recanalisation.
• Harm appeared as worse function, not as more symptomatic haemorrhage.
• Write the post-thrombectomy pressure ceiling into the unit protocol rather than leaving it to the shift.
• Recanalisation status changes the target - unsuccessful recanalisation was not what these trials tested.
• Review standing orders that carry over an intravenous antihypertensive from the pre-procedure phase.

Why it matters

The instinct after a successful procedure is to tidy the numbers, and this says that particular instinct costs function.

Don't overread it

Eight trials, and a group-level regression that cannot establish an individual patient's optimal pressure.

The statistics, in plain English

SUCRA is a ranking statistic, and a rank is less informative than an effect size: the wide interval on the top-ranked target, 50% to 100%, says the ordering itself is uncertain even though the direction is consistent. The proportional odds violation matters too - it means the effect of a target is not the same at every level of disability, so the single odds ratios are averages over patients who were affected differently.

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