Pol Camps-Renom, Marina Guasch-Jiménez, Juan Álvarez-Cienfuegos, Nicolás López-Hernández, Ana Rodríguez-Campello, Herbert Tejada-Meza, Luis López-Mesonero, Laura Albert-Lacal, M M Freijo-Guerrero, Diana Tarruella-Hernández, alan Flores, Juan Antonio Cabezas-Rodríguez, Joan Miquel Fernández-Vidal, Alejandro Martínez-Domeño, Natalia Pérez de la Ossa, Anna Ramos-Pachón, Ana Aguilera‐Simón, Rebeca Marín, Garbiñe Ezcurra‐Díaz, Álvaro Lambea-Gil, Yolanda Silva, Diego José Corona-García, Eva Giralt-Steinhauer, Javier Marta-Moreno, Jesús Alberto Vizcaya-Gaona, Ainara Sanz-Monllor, Alain Luna, Mikahela López Morales, Xavier Ustrell, Francisco Moniche, Judit Solà-Roca, X L Wang, C S Anderson, Luís Prats‐Sánchez, Joan Martí-Fàbregas, HOPE Study Group, Yaira Mathison, Juan Francisco Arenillas Lara, Mònica Millán, Mireia Puig Campmany, Jordi Branera, José Pablo González Martínes, Lavinia Dinia, Josep Munuera del Cerro, Andrea Lozano Martínez, Esther Granell, A. Perea, Ines Del Val, Lucia Borrego Escobar, Raquel Delgado Mederos, M.C. Domine, Melissa Coronel Coronel, Nerea Blanco Sanroman, Marc Delgado Romeu, Oscar López Lombardía, Patricia Carbonell Fernández, Jose Arriola, Tania Mederer, Maria Borrell, Raquel Sainz, Roger Collet Vidiella, Jesús Pérez Pérez, Elena Cortés Vicente, Álvaro Carbayo Viejo, Ana Vesperinas, Elba Pascual Goñi, Gonzalo Olmedo, Íñigo Ruiz Barrio, Laura Llansó, Marta Caballero, Ignacio Aracil, Nuole Zhu, Jesús García, Blanca Albertí, Raquel Arranz, Alberto Vegas, A. M. Silva, Angel Casco, Anna Gauchia, Ariadna López, Arnau Sanuy, Berta Garriga, Cristina García Burón, Cristina Riquelme, Elisabet Arcos, Eloi Ximenis, Emma Hidalgo, Encarna Jiménez, Eric Artiles, Eva Millán, Gabriela Serra, Gara Déniz, Guillem Arranz, Ignacio Martínez, Irene Bargueño, Iván Antón, Janira Castelló, Juan Alcaraz, Lluïsa Moscardó, Luz Pérez
Importance: Optimal blood pressure (BP) management after successful endovascular therapy for acute ischemic stroke remains uncertain, as intensive lowering has shown no benefit or potential harm in prior trials. Objective: To determine whether a reperfusion-guided systolic BP control strategy improves functional outcomes compared with guideline-recommended management after successful endovascular therapy for acute ischemic stroke. Design, Setting, and Participants: This investigator-initiated, multicenter, prospective, randomized, open-label clinical trial with blinded end point assessment was conducted among adults with acute ischemic stroke due to anterior circulation large-vessel occlusion who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score ≥2b) after endovascular therapy at 11 comprehensive stroke centers in Spain between June 14, 2021, and October 1, 2025, with 90-day follow-up. Data analysis was conducted from February 1 to March 12, 2026. Interventions: Participants were randomly assigned (1:1) to a reperfusion-guided systolic BP strategy (140-160 mm Hg for mTICI score of 2b; 100-140 mm Hg for mTICI score of 2c/3) or guideline-recommended management (systolic BP <180 mm Hg) for 72 hours using antihypertensive agents or vasopressors as needed. Main Outcomes and Measures: The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale score of 0 to 2 at 90 days, assessed in the intention-to-treat population. Of 446 enrolled patients, 440 were included in the intention-to-treat analysis (mean age, 75 years; 53% women); 6 were excluded due to withdrawal or consent withdrawal. Results: Among 440 patients (mean [SD] age, 75 [12] years; 233 [53.0%] women), 215 were assigned to the intervention group and 225 to the control group. At 90 days, 129 patients (60.0%) in the intervention group and 106 (47.1%) in the control group achieved a favorable functional outcome (absolute risk difference, 13.3%; 95% CI, 4.1%-22.6%; P = .005). Hemorrhagic transformation occurred in 48 patients (22.3%) in the intervention group and 71 (31.6%) in the control group (odds ratio, 0.62; 95% CI, 0.41-0.95). The rates of symptomatic intracranial hemorrhage (3.5% vs 3.9%) and 90-day mortality (15.4% vs 15.6%) did not differ between groups. Serious adverse events occurred in 34 patients (15.8%) in the intervention group and 27 (12.0%) in the control group. Conclusions and Relevance: In this randomized clinical trial, a reperfusion-guided BP strategy improved functional outcomes and reduced hemorrhagic transformation without increasing major safety events, supporting a tailored approach to postthrombectomy BP management. Trial Registration: ClinicalTrials.gov Identifier: NCT04892511.