Title : Blood pressure management during endovascular thrombectomy after the 2026 AHA/ASA stroke guideline: Implications for anesthetic practice; A narrative review
Abstract:
Introduction: Blood pressure (BP) management during endovascular thrombectomy (EVT) remains one of the most debated aspects of acute ischemic stroke care. While the 2026 American Heart Association/American Stroke Association (AHA/ASA) guideline advises against routine intensive systolic blood pressure (SBP) reduction below 140 mmHg following successful EVT, it provides limited guidance regarding intraprocedural hemodynamic management during general anesthesia. Because anesthesiologists directly influence cerebral perfusion throughout induction, thrombectomy, reperfusion, and emergence, understanding how contemporary stroke evidence translates into perioperative practice is essential. This review evaluates current evidence and proposes a practical framework for phase-specific BP management during EVT.
Methodology: A narrative review of contemporary literature was conducted using randomized controlled trials, systematic reviews, anesthesia-specific studies, and international guideline recommendations published through July 2026. Major post-EVT BP trials including BP-TARGET, ENCHANTED2/MT, BEST-II, OPTIMAL-BP, and the 2026 HOPE trials were critically reviewed alongside evidence comparing general anesthesia with procedural sedation. Studies evaluating intraprocedural hypotension, cerebral autoregulation, collateral perfusion, BP variability, and ongoing clinical investigations such as the MASTERSTROKE trial were also analyzed to determine their implications for anesthetic management.
Results and Discussion: Recent randomized evidence consistently demonstrates that routine intensive post-reperfusion SBP reduction below 140 mmHg does not improve neurological outcomes and may worsen functional recovery. The HOPE trial further suggests that individualized BP targets based on angiographic reperfusion status may improve outcomes compared with a uniform treatment strategy. In contrast, evidence addressing intraprocedural BP management remains limited. Observational studies indicate that sustained hypotension during vessel occlusion may compromise collateral-dependent cerebral perfusion and is associated with poorer neurological outcomes. Randomized anesthesia trials, however, demonstrate that protocolized general anesthesia achieves outcomes comparable to procedural sedation when treatment delays are minimized, and meticulous hemodynamic control is maintained. Collectively, these findings support shifting the focus from selecting an anesthetic technique to optimizing hemodynamic stability throughout each procedural phase. A phase-specific approach that avoids substantial hypotension before reperfusion, minimizes BP variability during thrombectomy, avoids indiscriminate aggressive BP reduction after reperfusion, and tailors management according to reperfusion status appears physiologically and clinically justified.
Conclusion: Contemporary evidence supports individualized rather than uniform BP management during EVT. Although the 2026 AHA/ASA guideline provides important recommendations for post-reperfusion care, significant uncertainty remains regarding optimal intraprocedural BP targets during general anesthesia. Until results from anesthesia-specific trials become available, anesthesiologists should prioritize preservation of collateral perfusion before reperfusion, prevention of marked BP variability, and individualized post-reperfusion management based on clinical and procedural context. These principles may improve multidisciplinary stroke care while informing future evidence-based anesthetic protocols.
