HOPE Supports Tailored Approach to BP After Stroke Thrombectomy

MAASTRICHT, the Netherlands—A one-size-fits-all approach does not appear to be the best way to go when it comes to managing blood pressure after endovascular thrombectomy for acute ischemic stroke, the randomized HOPE trial indicates.

Tailoring the BP goal to the completeness of reperfusion led to a 13.3% higher absolute rate of functional independence at 90 days compared with the guideline-recommended approach of keeping systolic BP below 180 mm Hg, Pol Camps-Renom, MD, PhD (Hospital de la Santa Creu i Sant Pau, Barcelona, Spain), reported here at the European Stroke Organisation Conference 2026.

The strategy also lessened the risk of hemorrhagic transformation, with no between-group differences in overall safety or mortality.

“I would suggest that the optimal BP management requires a more individualized approach than we have thought,” Camps-Renom said, noting that the findings “are in accordance with observational data, but are at odds with those reported by previous trials.”

Although observational studies have shown that high BP after thrombectomy is associated with poorer outcomes, the idea that intensive BP-lowering after the procedure could help patients has not borne out in trials such as BEST-II, BP-TARGET, ENCHANTED2/MT, and OPTIMAL-BP, with some indications of harm. Professional societies, including the American Heart Association/American Stroke Association, now recommend against being too aggressive with BP in this setting.

Use of the final modified Treatment in Cerebral Infarction (mTICI) score after thrombectomy to tailor BP goals was incorporated into HOPE “based on the premise that patients with an mTICI 2b may rely more heavily on collateral circulation and may be vulnerable to intensive BP-lowering,” and therefore might require a less aggressive BP goal, Camps-Renom explained.

Because of that, some other features of HOPE, and the discrepancy in the findings compared with prior trials, “our results should be interpreted right now more as hypothesis-generating than practice-changing,” he said, adding that the study provides “important methodological features that should be incorporated in the design of future trials.”

Eva Mistry, MBBS (University of Cincinnati, OH), who led BEST-II, called the approach studied in HOPE “intriguing,” but also said the results are not yet ready to influence day-to-day practice.

“I think that this trial is an outlier and has to be taken in context of that,” she told TCTMD.

The HOPE Trial

There are multiple possible reasons that the prior trials of BP management after thrombectomy were neutral or suggested harm, Camps-Renom said. Some of these include the selection of patients with impaired cerebral autoregulation, such as those with intracranial atherosclerotic disease; the use of a one-size-fits-all approach that doesn’t take into account the completeness of reperfusion achieved with the procedure; and the lack of protocolized use of vasopressors to protect against hypotension, he said.

The HOPE investigators sought to address these issues in their study, which was conducted at 11 stroke centers in Spain. Funding issues cut the trial short after 440 patients (mean age 75 years; 53% women) with acute ischemic stroke were enrolled. Participants had a stroke caused by a large-vessel occlusion in the anterior circulation, presented within 24 hours of symptom onset, and achieved successful recanalization, defined by an mTICI score of 2b or greater, after thrombectomy.

Patients were randomized to reperfusion-guided systolic BP control or guideline-recommended management (ie, a systolic BP goal < 180 mm Hg). For the tailored approach, patients with an mTICI score of 2b after the procedure had a systolic BP goal of 140-160 mm Hg, and those with an mTICI score of 2c/3 had a goal of 100-140 mm Hg.

Among the latter group, mean systolic BP in the first 24 hours was 125 mm Hg in the intervention arm and 135 mm Hg in the control arm, with vasopressors used in 11% and 2%, respectively. In the mTICI 2b subset, however, there was more variability in BP, with little difference between the trial arms.

The primary efficacy outcome was functional independence, defined as a score of 0-2 on the modified Rankin Scale (mRS) at 90 days. This was achieved by 60.0% of patients who received tailored BP goals and 46.7% of those in the control group (adjusted OR 1.71; 95% CI 1.11-2.63). Results were consistent across subgroups defined by age, sex, NIHSS score, ASPECTS, the presence of tandem occlusions, mTICI score, and time to admission.

The rate of hemorrhagic transformation also was lower with individualized BP goals (22.2% vs 31.6%; OR 0.62; 95% CI 0.41-0.95).

In terms of safety, there were no differences in rates of symptomatic intracerebral hemorrhage at 24 hours, neurological deterioration within 24 or 72 hours, or 90-day mortality (15% in both groups). The percentage of patients with at least one serious adverse event was 15.8% in the intervention group and 12.0% in the control group.

Unique Trial Features

Several characteristics of the trial need to be considered when interpreting the results in the context of prior studies, Camps-Renom indicated.

One was the use of the final mTICI score to tailor BP goals, although only about 10% of the participants fell into this category, a lower proportion than in BEST-II and ENCHANTED2/MT.

Protocolized use of vasopressors was a unique aspect of the trial as well, although only 10% of patients in the intervention group received them.

I’m not 100% convinced that putting many more resources in studying acute blood pressure targets [gives enough] bang for the buck. Eva Mistry

Possibly contributing to the beneficial effect of the strategy studied in HOPE was selection of patients expected to have more preserved cerebral autoregulation compared with prior trials, Camps-Renom said. Patients with nonrevascularized intra- or extracranial stenosis of at least 50% were excluded, leading to a lower rate of atherothrombotic strokes and a higher proportion of cardioembolic strokes. In addition, patients were not required to have hypertension to be included.

“All the distinctive methodological features of the trial and population characteristics . . . compared to previous trials may partly explain the benefits we have observed,” Camps-Renom said.

To TCTMD, Mistry noted that prior studies of intensive BP lowering were, at best, neutral in terms of improving outcomes. “At worst, several trials actually showed harm of lower blood pressure targets,” she said. “The achieved blood pressure values in these [trials] weren’t that different from HOPE.”

Another issue to consider is that grading of mTICI 2b based on the angiogram is not completely reliable, which could be playing into the HOPE results, Mistry said.

Asked whether it’s worth studying the individualized strategy from HOPE in another trial, she was doubtful. “I personally think that we have put in a lot of resources already in this question of blood pressure management in the acute setting. I think the answer may be in pooling the data that we already have [to] see if we find an answer there. I’m not 100% convinced that putting many more resources in studying acute blood pressure targets [gives enough] bang for the buck.”