Results of a new trial have re-awakened the possibility that blood pressure (BP) reduction following thrombectomy in patients with acute ischemic stroke (AIS) can be beneficial but with the caveat that BP targets may have to be individualized depending on patient-specific characteristics.

The HOPE trial showed that BP management intervention, with different targets for various levels of reperfusion achieved, improved functional outcomes after successful endovascular therapy.

This is the first clinical trial to demonstrate a benefit from BP reduction after thrombectomy; previous studies of intensive BP lowering — most conducted in Asia — showed either no benefit or even potential harm.

“Our trial reopens the debate about blood pressure lowering post-thrombectomy,” said lead investigator Pol Camps-Renom, MD, PhD, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.

However, he cautioned that the findings should be considered hypothesis-generating rather than practice-changing, noting that other studies reinforcing the point that other trials have failed to show benefit with intensive BP lowering after thrombectomy but added that the results “definitely give information about key factors that can be incorporated into future trials.”

“I think the idea that one size will not fit all patients is probably the way forward and that blood pressures will be individualized based on patient characteristics in future. But it is too premature to act on these data at present,” he added.

The study was presented on May 6 at the European Stroke Organization Conference (ESOC) 2026.

Hazard if Not Fully Reperfused?

Compared with previous trials of intensive BP lowering after thrombectomy, the HOPE trial used different BP targets according to the degree of reperfusion achieved at the end of the procedure.

“We did this because we were concerned about blood circulation in patients with incomplete reperfusion,” Camps-Renom noted.

He cited data suggesting that patients with incomplete reperfusion after thrombectomy rely more heavily on collateral circulation to maintain cerebral blood flow, raising concerns that overly aggressive BP lowering in these patients could compromise collateral perfusion and prove harmful.

The trial was therefore designed with two different BP treatment targets. Conducted at 11 stroke centres in Spain, the HOPE trial enrolled patients with anterior circulation AIS due to intracranial large vessel occlusion within 24 hours of symptom onset who achieved successful recanalization after endovascular thrombectomy, defined as modified treatment in cerebral infarction (mTICI) 2b or higher.

A total of 440 patients were randomized to receive either protocol-driven or guideline-recommended BP management. In the intervention arm, systolic BP targets were individualized according to final reperfusion status.

For participants with good reperfusion after thrombectomy (mTICI 2c/3, equating to reperfusion of 90%-100%), a systolic BP target of 100-140 mg Hg was recommended. In contrast, those with incomplete reperfusion (mTICI 2b flow, indicating a reperfusion of 50%-90%), a target of 140-160 mm Hg was advised.

Randomization to the trial BP intervention protocol or standard guideline-based management began 1 hour after the final angiographic series, followed by an additional hour to achieve the assigned systolic BP target.

The intervention was then maintained for 72 hours and included antihypertensive therapy or vasopressor support, as needed.

Why HOPE Succeeded

Results showed that the primary endpoint — a favorable functional outcome (modified Rankin Scale score of 0-2 at 90 days) was achieved in 60.0% of patients in the intervention group vs 46.7% in the control group (OR, 1.71; 95% CI, 1.17-2.50; P = .005).

The intervention group also showed a lower hemorrhagic transformation rate of 22.3% vs 31.6% in the control group (P = .030). The vast majority of patients enrolled in trial (90%) had good reperfusion rates, with only 10% of patients in the mTICI 2b group.

Camps-Renom suggested several possible explanations for why the HOPE trial showed benefit, whereas previous trials of intensive BP lowering after thrombectomy have been neutral or suggested harm.

He said the stratified approach to BP targets likely contributed to the positive findings in HOPE, although it is possible that other factors also played a role.

The use of vasopressors to keep patients in the specified BP range could have prevented harmful effects of lowering BP too much.

In addition, the HOPE trial enrolled a different patient population from the two major previous BP-lowering trials after thrombectomy — ENCHANTED2/MT and OPTIMAL-BP — both of which were conducted in Asia and likely included a higher proportion of patients with intracranial atherosclerosis.

The trial also excluded patients with significant intracranial or extracranial stenosis and included a higher proportion of individuals with cardioembolic stroke (60%), a group thought to derive greater benefit from BP reduction.

“We tended to select patients without vasculopathy, who would have had more preserved autoregulation and more preserved circulation,” said Camps-Renom.

Furthermore, unlike the Asian trials, the HOPE trial also did not require patients to be hypertensive before randomization.

“If patients were already in the target blood pressure range, we did not start the intervention — we just monitored them. We treated only to get into range,” said Camps-Renom.

Camps-Renom suggested that these differences from the earlier Asian trials may help explain the beneficial effects observed in HOPE.

“I think it’s a combination that we did not produce harm in patients with only partial reperfusion or significant atheroma, and we were selecting patients with more circulatory reserves,” he said.

The mean systolic BP achieved in the fully reperfused patients (mTICI 2c/3) was 135 mm Hg in the control group and 125 mm Hg in the Invention group, a difference of 10 mm Hg.

In the partial prefusion (mTICI 2b) patients, less difference was seen in achieved pressures — 139 mm Hg in the control group vs 143 mm Hg in the intervention group.

“So in practice the intervention only achieved a treatment effect in the fully reperfused group. The benefit was driven by this group, who made up the majority of the patients in the trial,” Camps-Renom said.

As a next step, the researchers plan to pool data from the various trials in this field and use those insights to design future studies aimed at confirming the findings of the HOPE trial.

Finding the Right Target

The findings also drew attention to the broader challenge of tailoring BP management after thrombectomy to individual patients.

Else Sandset, MD, PhD, Oslo University Hospital in Oslo, Norway, who wasn’t involved in the research, said the trial demonstrated that rigorous BP studies with stringent protocols are feasible in this setting and added that the results support a more individualized approach rather than a single BP target for all patients.

She pointed out that the use of vasopressors to actively raise BP in patients with hypotension was a novel aspect of the current study, but this could be complicated to implement.

Camps-Renom noted, however, that vasopressors were not used in many patients, so while this may have reduced some harmful effects, the impact would have been limited.

“Part of the benefit I think is due to the less frequent hemorrhagic transformation in the intervention group. We used quite a wide definition of hemorrhagic transformation, not just symptomatic ICH [intracerebral hemorrhage],” he said.

Sandset suggested that a more modest BP reduction compared to previous trials may also be a key factor in the positive results.

“In the majority of patients there was not a major drop in BP — possibly just enough to prevent hemorrhagic transformation without compromising perfusion. That might be one of the reasons why we see these benefits,” she concluded.

The HOPE trial was an investigator-initiated trial. Camps-Renom reported having no relevant disclosures.