Background Cerebral autoregulation is impaired in patients with large vessel occlusion (LVO) ischaemic stroke. Guidelines suggest intraprocedural systolic blood pressure (SBP) targets of 140-180 mmHg during endovascular thrombectomy (EVT). Higher SBP may increase penumbral blood flow, reduce infarct size and improve functional recovery, whereas lower SBP may reduce haemorrhagic transformation.
Methods MASTERSTROKE was a double-blind, randomised-controlled trial of anterior circulation LVO patients having EVT under general anaesthesia. Participants were randomised (1:1) to treatment arms of intra-procedural SBP 140±10 mmHg or 170±10 mmHg. The primary efficacy outcome was shift in modified Rankin Scale score (mRS) at day-90.
Results There were 562 patients (287 [51.0%] female, mean [SD] age 69.6 [14.5] years, baseline median [IQR] NIHSS 15 [11-20]); 280 randomised to the 140 mmHg and 282 to 170 mmHg treatment groups, respectively. Median achieved intra-procedural SBP was 141 (135-148) and 170 (162-177) mmHg. Day-90 median mRS score was 2 (1–4) in both groups (P=0.49). The proportion of participants with good functional recovery (mRS 0-2) was 54.9% and 51.1%, (OR 1.30 [95% CI, 0.80 to 2.11]; P =0.33). Symptomatic intracranial haemorrhage occurred in 2.1% and 2.1% (OR 0.99 [95% CI, 0.32-3.12]) and all-cause day-90 mortality was 12.1% and 15.2% (OR 0.87 [95% CI, 0.62-1.21]; P=0.28).
Conclusion This large multicentre trial is the first to test and achieve specific SBP targets during EVT. We provide class 1 evidence that there is no signal of additional benefit or harm across the 140-180 mmHg range of intra-procedural SBP recommended in current guidelines.