Katsanos, Aristeidis H.

BACKGROUND: Blood pressure management following successful reperfusion with endovascular thrombectomy for acute ischemic stroke due to large vessel occlusion remains debated. This meta-analysis aimed to determine whether intensive systolic blood pressure (SBP) management improves clinical outcomes compared with a standard approach after endovascular thrombectomy. METHODS: We systematically searched PubMed, Scopus, Embase, and Web of Science through October 2025 for relevant randomized controlled trials comparing intensive (SBP target <140 mm Hg) versus standard (SBP target <180 mm Hg) management. The primary efficacy and safety outcomes were functional independence (modified Rankin Scale score, 0–2) and any intracranial hemorrhage, respectively. We performed frequentist and Bayesian random-effects meta-analyses, supplemented by trial sequential analysis. RESULTS: Six randomized controlled trials comprising 1972 patients were included. In frequentist analysis, intensive SBP management was associated with a significantly reduced likelihood of achieving functional independence (risk ratio, 0.83 [95% CI, 0.73–0.93]). Bayesian analysis confirmed this harmful effect (posterior median risk ratio, 0.83 [95% credible interval, 0.7–1.02]), with a posterior probability of benefit of only 3.2%. Furthermore, ordinal shift analysis indicated that intensive SBP management was associated with a significant shift toward worse functional outcomes across the full modified Rankin Scale score distribution (common odds ratio, 1.26 [95% CI, 1.10–1.44]), a finding supported by a low posterior probability of benefit of 2.1%. No significant differences were observed in the risk of any intracranial hemorrhage (risk ratio, 1.05 [95% CI, 0.96–1.16]). The corresponding Bayesian analysis yielded a posterior risk ratio estimate of 1.05 (95% credible interval, 0.90–1.21) for any intracranial hemorrhage, with a posterior probability of benefit of 23%. Trial sequential analysis indicated that the cumulative evidence reached the boundary for harm and futility for the primary efficacy and safety outcomes, respectively. CONCLUSIONS: In patients with acute ischemic stroke following successful endovascular thrombectomy, intensive SBP management was associated with worse functional outcomes and provided no clear safety benefit. These findings support a standard, guideline-based SBP management strategy over an intensive approach.