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Barcelona, May 6, 2026. Managing blood pressure after thrombectomy in acute ischemic stroke may require a change in approach. The HOPE clinical trial—short 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 probably not all patients need the same approach,” said Dr. Pol Camps-Renom, head of the Cerebrovascular Diseases Research Group at IR Sant Pau and one of the study coordinators. “Our findings suggest that adjusting blood pressure according 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, Europe’s leading scientific society in stroke, and published simultaneously in JAMA Neurology, position this work among the most important 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 major breakthrough in the treatment of large-vessel occlusion stroke, making it possible to restore blood flow in previously blocked arteries. However, a well-recognized paradox remains in clinical practice: despite achieving 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 reopening the vessel does not always 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 transformation, all of which can compromise brain tissue viability even after a technically successful procedure.
“Many times we succeed in reopening the artery, but the brain tissue does not respond as expected,” explained Dr. Camps-Renom. “This is because microscopic-level perfusion and autoregulatory mechanisms may be impaired, and that is where factors such as blood pressure become critical.”
As a result, blood pressure control in the hours following thrombectomy has become a key component of clinical management, directly influencing the balance between maintaining adequate perfusion and avoiding hemorrhagic complications. However, the evidence available to date has been limited and, at times, contradictory. Previous trials based on uniform intensive blood pressure-lowering strategies have not demonstrated consistent benefits and have even suggested potential adverse effects.
An Individualized Approach Based on Reperfusion Pathophysiology
The HOPE trial introduces a different approach, based on the concept that hemodynamic management should be adapted to each patient’s pathophysiological status after thrombectomy. The study included 440 patients treated at 11 Spanish hospitals who were randomly assigned to either a conventional strategy or blood pressure management tailored to the degree of reperfusion.
Unlike previous trials, HOPE proposes a differentiated strategy based on the final angiographic result. Patients with near-complete or complete reperfusion were treated with lower blood pressure targets to reduce the risk of reperfusion injury, whereas those with incomplete reperfusion maintained higher targets to preserve cerebral perfusion.
This approach recognizes that the brain may be in very different hemodynamic states, in which both excessively high blood pressure and overly aggressive reduction may be harmful. Accordingly, the protocol included close monitoring during the first 72 hours, with dynamic treatment adjustments.
Improved Functional Recovery Without Increased Complications
This strategy resulted in 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% in the control group, representing an absolute difference of 13.3 percentage points, a clinically meaningful benefit. In addition, the overall analysis showed a favorable shift 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, 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 adding risks,” added Dr. Joan Martí-Fàbregas, another investigator involved in the study. “This balance between efficacy and safety is probably one of the most important aspects of the findings.”
Toward a Paradigm Shift in Post-Stroke Management
The results of the HOPE trial point toward a more individualized model of blood pressure management after thrombectomy. In a setting where previous trials had shown neutral or unfavorable results, this study introduces a physiology-based approach that optimizes the balance between perfusion and hemorrhagic risk.
Beyond its findings, HOPE provides key elements for the design of future studies, including stratification of therapeutic targets and prolonged hemodynamic monitoring. The study also reinforces the idea that stroke treatment does not end with recanalization but continues during the hours that follow. “Rather than applying rigid targets, the key is to better understand each patient’s physiology,” concluded Dr. Camps-Renom.
Although the trial was stopped before reaching its planned sample size, its results demonstrate a clinically meaningful effect size. Nevertheless, additional studies will be needed to confirm these findings before they can be broadly incorporated into clinical practice.
Overall, the HOPE trial positions blood pressure management as a key component in optimizing stroke treatment after thrombectomy and opens the door to more precise, patient-tailored strategies.
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Last update: 08 de June de 2026
