Blood pressure management after thrombectomy for acute ischemic stroke may require a change in approach. HOPE clinical trial (abbreviation) Hemodynamic optimization of cerebral perfusion after endovascular treatmentA research group led by the Saint-Pau Institute (IR Saint-Pau) has shown that adapting blood pressure targets to the degree of cerebral reperfusion significantly improves functional recovery in patients without increasing the risk of complications.
To date, we have applied a fairly uniform strategy after thrombectomy, but perhaps not all patients require the same approach. Our results suggest that adjusting blood pressure depending on the degree of reperfusion may directly impact recovery. ”
Dr. Pol Camps-Renom, head of the IR Sant Pau Cerebrovascular Disease Research Group and one of the research coordinators
The findings were presented at the plenary session of the annual meeting of the European Stroke Organization, Europe’s main scientific body specializing in stroke, and are currently being JAMA Neurology This study ranks among the most important recent contributions to the stroke field. These have the potential to guide new hemodynamic management strategies after thrombectomy.
Reopening the artery does not necessarily mean recovery
Mechanical thrombectomy represents a major advance in the treatment of large vessel occlusive stroke because it can restore blood flow to previously occluded arteries. However, well-known contradictions remain in clinical practice. Despite successful angiographic reperfusion, a significant proportion of patients (approximately half) do not achieve satisfactory functional recovery in the medium term.
This phenomenon, known as “clinically ineffective reperfusion,” reflects the fact that vascular recanalization does not necessarily result in effective restoration of cerebral perfusion at the tissue level. The mechanisms involved include reperfusion injury, microcirculatory dysfunction, loss of cerebral autoregulation, and hemorrhagic changes, all of which can compromise brain tissue viability even after technically successful interventions.
“In many cases, we can recanalize the artery, but the brain tissue does not respond as expected,” explains Dr. Pol Camps-Renom. “The reason is that microvascular perfusion and autoregulatory mechanisms may be impaired, and this is where factors such as blood pressure become important.”
As a result, blood pressure control in the hours following thrombectomy has become an important component of clinical management, as it directly affects the balance between maintaining adequate perfusion and avoiding hemorrhagic complications. However, the evidence available so far is limited and sometimes contradictory. Previous trials based on uniform intensive blood pressure lowering strategies have not demonstrated consistent efficacy and even suggest possible side effects.
Individualized approach based on reperfusion physiology
The HOPE trial introduces a different approach based on the concept that hemodynamic management should be adapted to each patient’s physiological state after thrombectomy. The study included 440 patients treated in 11 Spanish hospitals who were randomly assigned to either a conventional strategy or blood pressure control tailored to the degree of reperfusion achieved.
Unlike previous trials, HOPE implemented a differentiated strategy according to the final angiographic results. Patients with near-complete or complete reperfusion were treated with lower blood pressure targets to reduce the risk of reperfusion injury, whereas patients with incomplete reperfusion maintained higher blood pressure levels to maintain cerebral perfusion.
This approach recognizes that the brain can be in highly variable hemodynamic states and that both overly high blood pressure and overly aggressive blood pressure lowering can be detrimental. Therefore, the protocol included close monitoring and dynamic treatment adjustment during the first 72 hours.
Improve functional recovery without increasing complications
This strategy significantly and consistently improved clinical outcomes. At 90 days, 60.0% of patients in the intervention group achieved functional independence compared to 47.1% in the control group, an absolute difference of 13.3 percentage points and a clinically meaningful improvement. Moreover, the overall analysis showed a favorable trend towards a better level of recovery and strengthened the consistency of gains.
In terms of safety, this strategy is associated with a low incidence of hemorrhagic transformation without increasing mortality or serious complications, confirming a favorable balance between efficacy and safety. “We have shown that it is possible to improve patient recovery without increasing risk,” added Dr. Joao Martí Fabregas, another researcher involved in the study. “This balance between efficacy and safety is probably one of the most important aspects of our findings.”
Towards a paradigm shift in post-stroke management
The results of the HOPE trial point to a more personalized model for blood pressure control after thrombectomy. In the context of previous trials yielding neutral or unfavorable results, this study introduces a physiologically based approach that can optimize the balance between perfusion and bleeding risk.
In addition to its findings, HOPE provides important elements for the design of future studies, including therapeutic target stratification and long-term hemodynamic monitoring. This study also supports the idea that stroke treatment does not end with recanalization but continues for several hours afterward. “Rather than applying rigid targets, the key is a deeper understanding of each patient’s physiology,” concludes Dr. Camps-Renom.
Although the trial was stopped before the planned sample size was reached, the results demonstrate a clinically meaningful effect size. Nevertheless, additional studies will be needed to confirm these findings before they can be widely incorporated into daily clinical practice.
Overall, the HOPE trial positions blood pressure control as a key component for optimizing stroke treatment after thrombectomy and opens the door to more precise strategies tailored to individual patients.
sauce:
Institut de Recerca Sant Pau
Reference magazines:
Camps-Lennom, P., others. (2026) Individualized blood pressure goal setting after endovascular treatment for acute ischemic stroke: a randomized clinical trial. JAMA Neurology. DOI: 10.1001/jamaneurol.2026.1706. https://jamanetwork.com/journals/jamaneurology/fullarticle/2850074
