Individualizing Blood Pressure After Thrombectomy Improves Stroke Recovery

Blood pressure management after thrombectomy in acute ischemic stroke may require a change in approach. The HOPE clinical trial—an acronym for Hemodynamic Optimization of cerebral Perfusion after Endovascular therapy—led by the Sant Pau Research Institute (IR Sant Pau), has shown that adapting blood pressure targets to the degree of cerebral reperfusion significantly improves patients’ functional recovery, without increasing the risk of complications.

“Until now, we have applied fairly uniform strategies after thrombectomy, but not all patients probably need the same thing,” says Dr. Pol Camps-Renom, head of the Cerebrovascular Diseases research group at IR Sant Pau and one of the study coordinators. “Our results suggest that adjusting blood pressure to the degree of reperfusion can have a direct impact on recovery.”

The results, presented in a plenary session at the annual congress of the European Stroke Organisation, the leading European scientific society in stroke, and now published in JAMA Neurology, place this work among the most relevant recent contributions in the field of stroke, with the potential to guide new hemodynamic management strategies after thrombectomy.

Opening the Artery Does Not Always Translate Into Recovery

Mechanical thrombectomy has represented a decisive advance in the treatment of stroke caused by large vessel occlusion, as it makes it possible to restore blood flow in previously blocked arteries. However, a well-recognized paradox persists in clinical practice: despite achieving successful angiographic reperfusion, a significant proportion of patients—around half—do not achieve satisfactory functional recovery in the medium term.

This phenomenon, known as “clinically ineffective reperfusion,” reflects the fact that opening the vessel does not always translate into an effective restoration of cerebral perfusion at the tissue level. The mechanisms involved include reperfusion injury, microcirculatory dysfunction, loss of cerebral autoregulation, and the development of hemorrhagic transformation, all of which are processes that can compromise the viability of brain tissue even after a technically successful intervention.

“We often manage to reopen the artery, but the brain tissue does not respond as we expect,” explains Dr. Pol Camps-Renom. “This is because perfusion at the microscopic level and autoregulation mechanisms may be impaired, and this is where factors such as blood pressure become decisive.”

Thus, blood pressure control in the hours after thrombectomy has become established as a key element of clinical management, as it directly influences the balance between maintaining adequate perfusion and preventing hemorrhagic complications. However, the evidence available to date has been limited and, at times, contradictory. Previous trials based on uniform intensive reduction strategies have not shown consistent benefits and have even suggested possible adverse effects.

An Individualized Approach Based on the Pathophysiology of Reperfusion

The HOPE trial introduces a different approach, based on the idea that hemodynamic management should be adapted to each patient’s pathophysiological situation after thrombectomy. The study included 440 patients treated at 11 Spanish hospitals, randomly assigned to either a conventional strategy or blood pressure control adjusted to the degree of reperfusion.

Unlike previous trials, HOPE proposes a differentiated strategy according to the final angiographic result. Thus, patients with near-complete or complete reperfusion were treated with lower pressure targets to reduce the risk of reperfusion injury, while higher levels were maintained in those with incomplete reperfusion to preserve cerebral perfusion.

This approach recognizes that the brain may be in extremely diverse hemodynamic situations, in which both excessive blood pressure and overly aggressive reduction can be harmful. For this reason, the protocol included close monitoring during the first 72 hours, with dynamic treatment adjustments.

Better Functional Recovery Without an Increase in Complications

This approach translated into a significant and consistent improvement in clinical outcomes. At 90 days, 60.0% of patients in the intervention group achieved functional independence, compared with 47.1%, representing an absolute difference of 13.3 percentage points, which is clinically relevant. In addition, the overall analysis showed a favorable trend toward better levels of recovery, reinforcing the consistency of the benefit.

In terms of safety, the strategy was associated with a lower incidence of hemorrhagic transformation, with no increase in mortality or serious complications, confirming a favorable balance between efficacy and safety. “We have observed that it is possible to improve patients’ recovery without adding risks,” adds Dr. Joan Martí-Fàbregas, another of the investigators who took part in the study. “This balance between efficacy and safety is probably one of the most relevant aspects of the results.”

Toward a Paradigm Shift in Post-Stroke Management

The results of the HOPE trial point toward a more individualized model for blood pressure control after thrombectomy. In a field where previous trials had shown neutral or unfavorable results, this study introduces a pathophysiology-based approach that makes it possible to optimize the balance between perfusion and hemorrhagic risk.

Beyond its results, HOPE provides key elements for the design of future studies, such as the stratification of therapeutic targets and prolonged hemodynamic monitoring. The study also reinforces the idea that stroke treatment does not end with recanalization but continues in the hours that follow. “Rather than applying rigid targets, the key is to better understand each patient’s physiology,” concludes Camps-Renom.

Although the trial was stopped before reaching the planned sample size, its results show a clinically relevant magnitude of effect. Nevertheless, they will need to be confirmed in additional studies before being widely incorporated into clinical practice.

Overall, the HOPE trial positions blood pressure control as a key component in optimizing stroke treatment after thrombectomy and opens the door to more precise strategies adapted to each patient.

Reference Article: Camps-Renom P, Guasch-Jiménez M, Álvarez-Cienfuegos J, López-Hernández N, Rodríguez-Campello A, Tejada-Meza H, López-Mesonero L, Albert-Lacal L, Freijo-Guerrero MM, Tarruella-Hernández D, Flores A, Cabezas-Rodríguez JA, Fernández-Vidal JM, Martínez-Domeño A, Pérez de la Ossa N, Ramos-Pachón A, Aguilera-Simón A, Marín R, Ezcurra-Díaz G, Lambea-Gil Á, Silva Y, Corona-García DJ, Giralt-Steinhauer E, Marta-Moreno J, Vizcaya-Gaona JA, Sanz-Monllor A, Luna A, López Morales M, Ustrell X, Moniche F, Solà-Roca J, Wang X, Anderson CS, Prats-Sánchez L, Martí-Fàbregas J, HOPE Study Group. Personalized blood pressure targeting after endovascular therapy for acute ischemic stroke: A randomized clinical trial: A randomized clinical trial. JAMA Neurol 2026. https://doi.org/10.1001/jamaneurol.2026.1706