HOPE Supports Tailored Approach to BP After Stroke Thrombectomy

Why It Matters

If confirmed, tailoring blood‑pressure targets to reperfusion quality could improve recovery after stroke thrombectomy, challenging current guideline recommendations that favor a uniform systolic limit.

Key Takeaways

• Tailored BP targets based on mTICI improved functional independence by 13.3%.
• Hemorrhagic transformation reduced from 31.6% to 22.2% with individualized BP.
• No difference in mortality or serious adverse events between strategies.
• Trial halted at 440 patients, limiting statistical power.
• Experts view findings as hypothesis‑generating, not ready for practice change.

Pulse Analysis

Blood‑pressure management after endovascular thrombectomy has long been a contentious issue. Observational data link high post‑procedure pressures to poorer outcomes, yet major trials such as BEST‑II, BP‑TARGET, ENCHANTED2/MT, and OPTIMAL‑BP have failed to demonstrate a clear benefit from aggressive lowering, prompting societies like the AHA/ASA to advise against intensive control. These mixed results stem partly from a one‑size‑fits‑all design that ignores the degree of reperfusion achieved, as well as variability in vasopressor use and patient selection.

The HOPE trial introduced a nuanced protocol that aligned systolic targets with the final modified Treatment in Cerebral Infarction (mTICI) score. Patients with near‑complete reperfusion (mTICI 2c/3) were kept at 100‑140 mm Hg, while those with moderate reperfusion (mTICI 2b) were allowed 140‑160 mm Hg. This stratification produced a 13.3‑point lift in the proportion of patients attaining functional independence (mRS 0‑2) at three months and cut hemorrhagic transformation by roughly 10 percentage points, without raising mortality or serious adverse events. The trial’s protocolized vasopressor use and exclusion of patients with significant intracranial atherosclerosis further differentiated its cohort from earlier studies.

Despite these promising signals, the HOPE investigators caution that the findings are hypothesis‑generating. The study closed early after enrolling 440 participants, limiting power and generalizability. Stroke experts argue that larger, pooled analyses may be a more efficient path to resolve the BP‑target debate than launching another costly trial. Nonetheless, the trial underscores the potential of personalized hemodynamic management in acute stroke care, a concept that could reshape future guidelines if validated by broader evidence.