Effective BP management after EVT is critical for maintaining optimal cerebral perfusion and protecting the brain from harmful hypo- or hyperperfusion. How to best manage BP during the early stages of LVO stroke remains uncertain, as a single, universal BP target below 180/105 mmHg is likely inadequate in this highly heterogeneous patient population. 

To determine individualized, autoregulation-based blood pressure (BP) targets for patients with LVO stroke undergoing endovascular therapy (EVT), and to assess how exceeding limits of autoregulation (LA) relates to neurologic worsening and functional outcome. 

We prospectively enrolled 52 patients with LVO stroke undergoing EVT. Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy derived tissue-oxygenation and mean arterial pressure (MAP). The resulting autoregulatory index was used to identify and trend the BP range at which autoregulation was most preserved. The percent time that MAP exceeded the upper and lower limit of autoregulation was calculated for each patient. Neurologic worsening was defined as an increase of 4 points in the NIHSS during the first 24hrs. Functional outcome was assessed using the modified Rankin Scale (mRS). Associations among percent time outside LA, neurologic worsening, and mRS were assessed using binary and ordinal logistic regression, adjusting for age, sex, TICI score, baseline NIHSS and ASPECTS.

Personalized LA were computed in all patients (age 70±15, 22F, mean NIHSS 14±6, monitoring time 25±12 hours, neurologic worsening=14). Optimal blood pressure and LA were calculated for 87±10% of the total monitoring period. Percent time with MAP outside limits of autoregulation was significantly associated with neurologic deterioration (p=0.017) and worse functional outcome at discharge (p=0.031) and 90 days (p=0.01).

Non-invasive determination of personalized BP thresholds for stroke patients is feasible. Exceeding individualized limits of autoregulation may increase the risk of neurologic worsening and poor functional outcomes.