Intensive Blood Pressure Lowering in Acute Stroke with Intracranial Stenosis Post-Thrombectomy: a secondary analysis of the OPTIMAL-BP trial

Background: Intensive blood pressure (BP) management within 24 hours after successful reperfusion following endovascular thrombectomy (EVT) is associated with worse functional outcomes than conventional BP management in Asian randomized controlled trials. Given the high prevalence of intracranial atherosclerotic stenosis (ICAS) in Asia, ICAS may influence these outcomes. Aims: We aimed to assess whether ICAS affects the outcomes of intensive BP management after successful EVT. Methods: We conducted a secondary analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy–Optimal Blood Pressure Control trial, which enrolled participants from June 2020 to November 2022. Patients with anterior circulation large vessel occlusion (LVO) were stratified into ICAS-related and embolic LVO groups. Clinical outcomes for intensive (target systolic BP<140 mmHg) and conventional BP management (target systolic BP 140-180 mmHg) were analyzed in each group. The primary outcome was a favorable outcome, defined as a modified Rankin Scale score of 0 to 2 at 3 months. Safety outcomes included symptomatic intracerebral hemorrhage within 36 hours and stroke-related death within 3 months. Results: Among 192 patients, 59 were in the ICAS-related LVO group, and 133 were in the embolic LVO group. In the ICAS-related LVO group, the rate of achieving a favorable outcome at 3 months was 37.5% with intensive BP management and 55.6% with conventional management (adjusted OR, 0.49 [95% CI, 0.14-1.75]; P=0.27). In the embolic LVO group, these rates were 29.9% and 42.4%, respectively (adjusted OR, 0.64 [95% CI, 0.28-1.45]; P=0.29). No significant interaction was found (P for interaction=0.68). Additionally, the ICAS-related LVO group receiving intensive BP management had lower rates of successful reperfusion at 24 hours compared to conventional management (67.7% vs 91.7%; P=0.03), while no significant difference was found in the embolic LVO group. A significant interaction effect on successful reperfusion at 24 hours was observed between ICAS-related and embolic LVO groups (P for interaction=0.04). No significant differences in safety outcomes were observed between intensive BP management and conventional management within both ICAS-related LVO and embolic LVO groups. Conclusions: ICAS did not significantly affect outcomes of intensive BP management within 24 hours after successful EVT. After successful reperfusion by EVT, intensive BP management should be avoided regardless of ICAS presence.