Blood pressure management after mechanical thrombectomy is as crucial as reperfusion status in acute large vessel occlusion

Background: Blood pressure variability (BPV) is known to influence outcomes after mechanical thrombectomy (MT) in acute large vessel occlusion (LVO), and its impact may vary depending on the degree of collateral flow prior to MT. This study aimed to investigate whether BPV after MT has a differential impact on 90-day functional outcomes according to the hypoperfusion intensity ratio (HIR) derived from perfusion MRI processed by RAPID software.

Methods: Patients with anterior circulation LVO who underwent emergency MT between 2020 and 2023 and had pre-procedural perfusion MRI processed by RAPID software were enrolled. Multivariate logistic regression models were used to examine the association between BPV and 90-day functional outcomes, defined by modified Rankin Scale (mRS) scores. The cut-off values for BPV and HIR were determined based on their median values, and a composite variable was created to analyze the interaction between BPV and HIR.

Results: A total of 209 patients were included in the study. The cut-off values for BPV and HIR were 8.27 and 0.37, respectively. Patients with both high pre-procedural HIR and high post-procedural BPV had a 78.3% incidence of poor 90-day outcomes, which was significantly higher than that in the other groups. In multivariate logistic regression analysis, high HIR and high BPV (OR = 4.72; 95% CI, 1.61–13.9; p < 0.01) independently predicted poor outcomes, with an effect comparable to that of post-procedural reperfusion status (OR = 5.67; 95% CI, 1.80–17.8; p < 0.01).

Conclusion: In acute LVO, patients with high BPV and poor collateral flow on pre-procedural MRI are more likely to experience unfavorable clinical outcomes. Maintaining stable and appropriate blood pressure in the intensive care unit after MT is crucial for optimizing recovery in these patients.

Dr. Jin-Heon Jeong is a neurologist and neurocritical care specialist with extensive expertise in intensive care management and neurological emergencies. He graduated from Seoul National University College of Medicine and completed specialty training in neurology. Currently serving as Professor at Dong-A University and Director of the Neurocritical Care Unit.