Abstract / Summary
BACKGROUND: Optimal blood pressure management during endovascular therapy (EVT) for acute ischemic stroke remains uncertain. Intraprocedural hypotension may compromise cerebral perfusion and worsen neurological outcomes, yet existing evidence is inconsistent, and no prior meta-analysis has synthesized observational data on intraoperative hypotension during EVT. METHODS: We conducted a systematic review and meta-analysis of studies evaluating the association between intraoperative hypotension and outcomes in patients undergoing EVT for acute ischemic stroke. MEDLINE and Embase were searched from inception to May 2024 without language restrictions. Eligible studies enrolled adult patients undergoing EVT with reported intraoperative blood pressure data and prespecified clinical outcomes. The primary outcome was favorable functional outcome (modified Rankin Scale score, 0–2) at 90 days. Secondary outcomes included failure of reperfusion (Thrombolysis in Cerebral Infarction <2b), early neurological improvement, final infarct volume, and symptomatic intracranial hemorrhage. Pooled odds ratios with 95% CIs were estimated using random-effects models. Risk of bias was assessed with the Risk of Bias in Nonrandomized Studies of Interventions tool and certainty of evidence with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. RESULTS: Nine studies comprising 1737 patients were included in the systematic review, of which 7 contributed to quantitative synthesis. Intraoperative hypotension was significantly associated with lower odds of favorable functional outcome (odds ratio, 0.55 [95% CI, 0.41–0.74]; I 2 =0%). No significant association was found between hypotension and failure of reperfusion (odds ratio, 1.36 [95% CI, 0.85–2.18]). Evidence regarding early neurological improvement was limited. Narrative synthesis indicated that greater cumulative exposure to hypotension correlated with larger final infarct volumes. Certainty of evidence was rated high for favorable functional outcome and low for failure of reperfusion. CONCLUSIONS: Intraoperative hypotension during EVT, defined as mean arterial pressure below 60 to 70 mm Hg or a relative decrease of ≥20% to 40% from baseline, is associated with worse 90-day functional outcomes, independent of reperfusion status. These findings support hemodynamic monitoring during EVT and suggest that intraoperative hypotension is associated with worse functional outcomes.