Beyond Absolute Blood Pressure Targets During Endovascular Thrombectomy: A Narrative Review of Intraprocedural Hemodynamics.
7 affiliations
- 1Anesthesiology and Critical Care, Rand Memorial Hospital, Freeport, BHS.
- 2Anesthesiology and Critical Care, Sri Venkateswara Institute of Medical Sciences, Tirupati, IND.
- 3Anesthesiology, Rand Memorial Hospital, Freeport, BHS.
- 4Anesthesiology, University of Texas (UT) Health Medical Center, Houston, USA.
- 5Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, USA.
- 6Internal Medicine, Cheyenne Regional Medical Center, Cheyenne, USA.
- 7Internal Medicine, Rajiv Gandhi Institute of Medical Sciences, Adilabad, IND.
Abstract
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 arterial-pressure 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.
Related
- Endovascular thrombectomy activity as a candidate marker of organised acute stroke-service capacity: a global burden of disease-based European panel study
- Endovascular thrombectomy for acute ischemic stroke with large infarct core: translating results from a randomized trial into clinical practice
- Endovascular thrombectomy for mild vertebrobasilar artery occlusion: a hierarchical win-ratio analysis
- Technical considerations in endovascular thrombectomy for distal vessel occlusions
- Endovascular mechanical thrombectomy for the treatment of extensive postpartum cerebral venous sinus thrombosis: a case report
BibTeX
@article{veeramachaneni2026beyond,
title = {{Beyond Absolute Blood Pressure Targets During Endovascular Thrombectomy: A Narrative Review of Intraprocedural Hemodynamics.}},
author = {Rajesh Veeramachaneni and Gadidesi Kalyani and Revathi Lokala and Abhishek Prasad and Nishank Patel Nooli and Raja Shekar Jadav and Sai Abhinay Reddy and Vincent Burton},
journal = {Cureus},
year = {2026},
month = oct,
doi = {10.7759/cureus.117604},
url = {https://europepmc.org/article/MED/42997865},
note = {CC BY},
}
RIS
TY - JOUR
TI - Beyond Absolute Blood Pressure Targets During Endovascular Thrombectomy: A Narrative Review of Intraprocedural Hemodynamics.
AU - Rajesh Veeramachaneni
AU - Gadidesi Kalyani
AU - Revathi Lokala
AU - Abhishek Prasad
AU - Nishank Patel Nooli
AU - Raja Shekar Jadav
AU - Sai Abhinay Reddy
AU - Vincent Burton
PY - 2026
DA - 2026/10/07
JO - Cureus
DO - 10.7759/cureus.117604
UR - https://europepmc.org/article/MED/42997865
AB - 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 arterial-pressure 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.
SN - 2168-8184
ER -