Late-breaking research presented at the 2026 World Stroke Congress (WSC; 21–23 October, Seoul, South Korea) has provided fresh insights on the benefits of individualised strategies for post-thrombectomy blood pressure (BP) management—including the potentially significant role played by haemorrhagic transformation (HT) incidence, as well as the possible adverse impact of intensive BP lowering in patients who have undergone endovascular treatment.
Optimal BP management remains a pressing, unresolved problem following a successful mechanical thrombectomy for acute ischaemic stroke. In recent years, several clinical trials—BP-TARGET, ENCHANTED2/MT, OPTIMAL-BP and BEST II—have produced definitive evidence that intensive, ‘one-size-fits-all’ BP control is not the answer; despite evaluating targets ranging from 100–129mmHg in BP-TARGET to <160mmHg in BEST II, the four trials collectively indicate that non-individualised strategies are, at best, futile in improving functional independence rates and reducing symptomatic intracranial haemorrhage (sICH), and, at worst, may be linked to worse functional outcomes and increased mortality.
A far more promising signal comes from the aptly named HOPE trial, published earlier this year in JAMA Neurology, which showed that tailoring BP control based on the degree of reperfusion achieved by each patient can lead to improved functional outcomes and reduced HT without increasing major safety events. In this prospective, randomised trial’s treatment arm, patients who achieved modified thrombolysis in cerebral infarction (mTICI) 2c–3 reperfusion were assigned a systolic BP target of 100–140mmHg, and those who achieved mTICI 2b reperfusion were assigned a target of 140–160mmHg, while patients in the control arm had a systolic BP target of <180mmHg.
New HOPE trial data
Now, a secondary analysis of HOPE has revealed new insights on the specific relationship between reperfusion-guided BP management and HT. This analysis—shared for the first time by Joan Miquel Fernández-Vidal (Hospital de la Santa Creu i Sant Pau, Barcelona, Spain) at WSC 2026—solely included the 397 (90.2%) HOPE trial patients who achieved mTICI 2c–3, as this subgroup was found to have experienced an overall clinical benefit, whereas the mTICI 2b subgroup did not. Its primary endpoint was the occurrence of any HT, while HT subtype and sICH were among secondary endpoints of interest.
The analysis showed that, of the 139 patients with HT, 42.6% were in the standard BP management group and 30.9% were in the individualised group (odds ratio [OR], 0.57). This statistically significant difference across the two study arms was maintained after the researchers adjusted for multiple baseline characteristics that differed between groups, including Alberta stroke programme early computed tomography score (ASPECTS), National Institutes of Health stroke scale (NIHSS) score, number of thrombectomy passes, and time from symptom onset to randomisation (adjusted OR, 0.62).
“It’s also important to highlight that, even though the numbers of any HT were different, there were no differences in the HT subtypes or sICH rates,” Fernández-Vidal told NeuroNews. “This underscores the increasingly popular idea that asymptomatic HTs are not necessarily clinically unimportant—especially given that patients with HT had a worse functional outcome at three months [modified Rankin scale (mRS) 0–2, 39.1% with HT versus 64.7% without HT] in this analysis.”
Further examinations revealed that patients with HT were not more hypertensive at the point of randomisation compared to those without HT. In Fernández-Vidal’s view, this is significant, as hypertension at randomisation has been part of the inclusion criteria for prior trials in this space.
Additionally, a restricted cubic spline analysis performed by the researchers showed that, while the relationship between systolic BP levels and HT appears to be non-linear, a mean systolic BP ≥160mmHg demonstrated a significant association with increased HT likelihood at both 0–12 and 0–24 hours. As such, Fernández-Vidal concluded his presentation by noting that, based on these analyses, a mean systolic BP of less than 160mmHg during the first 12 hours after thrombectomy has emerged as a potential population-level threshold in patients who achieve mTICI 2c–3.
“Patients in the individualised treatment group were also significantly less likely to be exposed to systolic BP levels above this threshold,” he added. “But, even though we have identified a potential threshold for mean systolic BP, it’s about more than just a single reading above this threshold—it’s about sustained exposure during the first 12–24 hours. This shouldn’t be interpreted as ‘the lower, the better’. Rather, there is a need to avoid high and sustained levels of systolic BP in patients with mTICI 2c–3 post-thrombectomy.”
Furthermore, while this analysis sheds new light on the role played by HT, Fernández-Vidal believes key gaps remain in the stroke community’s knowledge of post-thrombectomy BP management.
“We are still trying to fully explain why the HOPE trial was positive, and I think it is multifactorial as opposed to just one thing,” he stated. “One hypothesis is that those patients [who underwent tailored BP control] had lower HT incidence, but we are looking at collaterals and looking to see if they had less oedema as well. We are also planning another trial—the HOPE 2 trial—that will assess post-thrombectomy BP control using a bigger sample size, across a greater number of countries and different ethnicities, as well as using CT [computed tomography] or MRI [magnetic resonance imaging] scans to more accurately determine whether patients have HT during the first few hours after a thrombectomy.”
Updated evidence on intensive BP lowering
Another late-breaking presentation at WSC 2026 saw researchers share new findings from the OPTEC meta-analysis. As per pooled individual participant data from seven randomised trials involving 2,412 adults with acute ischaemic stroke due to large vessel occlusion (LVO) who underwent successful reperfusion via mechanical thrombectomy, intensive BP lowering appeared to worsen functional outcomes at 90 days without demonstrating a reduction in sICH.
The researchers believe that, having largely confirmed the prior findings of trials like BP-TARGET, ENCHANTED2/MT, OPTIMAL-BP and BEST II, this meta-analysis strengthens current evidence against routinely pursuing intensive targets. The analysis also identified patient characteristics that may influence susceptibility to harm as a result of intensive BP lowering.
Presenting these data at WSC 2026, Xia Wang (The George Institute for Global Health, Sydney, Australia) initially noted that the mean patient age was 71 years and the average baseline systolic BP level was 151mmHg. She also relayed that the majority of participants (62%) were recruited in Asian healthcare settings.
The trials included in the OPTEC meta-analysis compared different intensive strategies with their respective standard management protocols, and ultimately showed that—among 2,381 participants with available outcome data—intensive treatment shifted the mRS distribution towards greater disability or death, with an adjusted common OR of 1.16 (95% confidence interval [CI], 1.01–1.34; p=0.041). The primary model accounted for trial differences, baseline stroke severity and time from symptom onset to randomisation. According to Wang, sICH occurred in 9.6% with intensive BP management versus 8.7% with standard BP management (adjusted OR, 1.10; 95% CI, 0.83–1.46), while mortality alone did not differ significantly between the two groups.
“OPTEC’s principal contribution is harmonised analysis of individual records across diverse populations and treatment strategies, allowing consistent adjustment and examination of treatment-effect heterogeneity beyond published trial averages,” Wang commented, discussing these findings with NeuroNews. “It also incorporates the HOPE trial, which reported benefit from a reperfusion-guided protocol, bringing contrasting contemporary evidence into the synthesis. Prespecified analyses suggested effect modification by baseline systolic pressure and collateral status, with nominal interaction p-values of 0.026 and 0.008, respectively. Higher starting pressure and poor collaterals were associated with greater harm.”
Wang went on to state that, from a clinical standpoint, OPTEC reinforces the 2026 American Heart Association (AHA)/American Stroke Association (ASA) recommendation that advises against targeting systolic BP levels below 140mmHg during the first 72 hours after successful anterior-circulation thrombectomy “when no alternative indication dictates management”.
“Successful macrovascular recanalisation may coexist with impaired microvascular perfusion and autoregulation, offering a plausible explanation for harm from intensive lowering,” she continued. “However, OPTEC does not prove that mechanism or justify routinely augmenting spontaneously lower pressure. For clinicians, the immediate implication is to avoid automatic escalation towards intensive low targets after reperfusion while assessing neurological status and competing haemodynamic indications.”
Finally, regarding directions for future research, Wang indicated that the priority should now be the prospective testing of perfusion-informed strategies that preserve tissue blood flow and establish whether individualised targets improve outcomes—a conclusion that aligns neatly with the HOPE trial investigators’ plans to conduct a second, larger study evaluating these factors more closely.
