Optimal Systolic Blood pressure control after thrombectomy in acute ischemic stroke-a systematic review and metaanalysis

Introduction Although endovascular thrombectomy(EVT) is the standard of care for acute large vessel occlusions, ideal systolic blood pressure (SBP) target post procedure has remained elusive. With recent publications of randomised controlled trials (RCTs) comparing intensive BP control to a less intensive strategy, there is a need to conduct a systematic review and meta-analysis on existing studies for a timely update. Our study aimed to address the question of whether in adult patients of acute ischemic stroke who undergo EVT does an intensive blood pressure control as compared to a less intensive blood pressure control/conventional control up to 24 hours after procedure lead to a good functional outcome as defined by modified Rankin score(mRS) of 0-2 at 90days. Methods We used the PRISMA guidelines for this systematic review. Databases were searched for English language articles using predefined search terms till Sep 15 2023. Risk of bias was assessed using the New Castle Ottawa scale(NOS) for observational studies, and the revised Cochrane risk-of-bias 2 (ROB2) tool for RCTs. The primary outcome was mRS 0-2 at 90days. Results 72 full text studies were assessed for eligibility and twelve studies (5439 patients-eight observational and four RCTs) were included in the final analysis. The primary outcome was not significantly different between both the arms(RR-1.16 ; 95%CI-0.98-1.37; p=0.08).There were no significant differences in the mortality at 90days and the risk of symptomatic intracranial haemorrhage(RR-death:0.83;95%CI-0.68-1.02;p=0.08,RR-symptomatic intracranial haemorrhage:0.84;95%CI-0.61-1.16;p=0.29). Fewer patients required decompressive surgery in the intensive arm(RR-0.40; 95%CI-0.25-0.66; p=0.0003). A separate analysis of observational studies and RCTs for the primary outcome showed that observational studies favoured intensive control(RR-1.34;95%CI-1.20-1.48; p<0.00001) whereas data from RCTs favoured conventional control(RR-0.82;95%CI-0.72-0.93;p=0.003). Conclusion The results of this meta-analysis suggest that neither intensive nor conventional SBP control resulted in better functional outcomes but intensive control had a significant effect by reducing the need for decompression. Further RCT?s will help strengthen evidence. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement None ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Not required as this is a systematic review/meta-analysis I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data referred in the manuscript is copyright of the authors and should be appropriately.