Beyond Absolute Blood Pressure Targets During Endovascular Thrombectomy: A Narrative Review of Intraprocedural Hemodynamics

Hemodynamic management is a central component of procedural care for acute ischemic stroke (AIS) during endovascular thrombectomy (EVT).Current guideline recommendations predominantly provide absolute blood pressure (BP) targets for intraprocedural management.Studies have also examined relative BP reduction, the magnitude and duration of hypotensive exposure, and blood pressure variability (BPV), providing additional measures of systemic hemodynamic exposure during EVT.However, definitions, baseline reference pressures, measurement intervals, and BPV metrics vary widely across studies, and associations with neurological outcomes are inconsistent.Importantly, these systemic BP parameters do not directly establish cerebral perfusion.This limitation supports investigating cerebral autoregulation as a complementary, patient-specific assessment.Evidence linking individualized autoregulatory limits to outcomes remains predominantly post-EVT, with very limited evidence during the pre-recanalization phase under anesthesia.This review examines intraprocedural BP during EVT under anesthesia beyond absolute pressure targets.It considers relative BP reduction, the magnitude and duration of hypotensive exposure, pressure-time burden, BPV, and individualized autoregulatory limits in relation to cerebral perfusion.A narrative literature search was conducted in PubMed for studies evaluating hemodynamics during EVT under anesthesia, supplemented by screening of selected reference lists.Studies examining intraprocedural BP targets, relative changes, hypotension duration, pressure-time burden, and BPV in relation to neurological or imaging outcomes under anesthesia were prioritized, with emphasis on the pre-recanalization period.Post-EVT hemodynamic studies were not included in the primary synthesis, except where they informed the discussion of cerebral autoregulation and future research.Intraprocedural hemodynamic variables during EVT characterize different aspects of systemic arterialpressure exposure that may be relevant to cerebral perfusion in the ischemic penumbra.Absolute pressure, relative change, magnitude and duration of hypotension, pressure-time burden, and BPV should be regarded as complementary rather than interchangeable measures.Differences in reference pressures, definitions, measurement intervals, exposure periods relative to recanalization, and anesthesia techniques limit comparisons and standardization across studies.Future prospective studies, particularly during general anesthesia (GA), should integrate clearly defined systemic BP metrics with dynamic cerebral autoregulation.This may help determine which parameters or combinations best reflect cerebral physiological vulnerability.Individualized autoregulation-guided BP targets remain investigational and require prospective validation before they can inform routine clinical hemodynamic management.