# Impact of Intraprocedural Pulse Pressure During Mechanical Thrombectomy on Functional and Radiological Outcomes in Patients with Acute Ischemic Stroke

## TL;DR

This study finds that higher pulse pressure during mechanical thrombectomy for stroke is linked to worse outcomes, suggesting it should be monitored closely.

## Contribution

The study identifies pulse pressure as a novel hemodynamic target during mechanical thrombectomy for acute ischemic stroke.

## Key findings

- Higher median pulse pressure during EVT independently predicted poor functional and radiological outcomes.
- Longer exposure to elevated pulse pressure (>50 mmHg) was associated with worse outcomes and brain complications.
- Adding median pulse pressure to existing models improved their predictive accuracy.

## Abstract

Background/Objectives: Periprocedural blood pressure influences outcomes after endovascular treatment (EVT), but the impact of pulse pressure (PP) remains unclear. We assessed associations between intraprocedural PP and clinical and radiological outcomes after EVT. Methods: We retrospectively analyzed adults with acute ischemic stroke (AIS) due to proximal anterior circulation large vessel occlusion treated with EVT under general anesthesia. Non-invasive BP was recorded every 5 min during EVT. From these recordings, we derived baseline, maximal, minimal, and median PP, PP variability indices, and cumulative time above predefined PP thresholds. The primary endpoint was poor functional outcome at 90 days (modified Rankin Scale 3–6). Secondary endpoints were final infarct volume (FIV), malignant brain edema (MBE), symptomatic intracranial hemorrhage (sICH), and hemorrhagic transformation (HT). Multivariable regression models were adjusted for established prognostic factors. Results: In the 217 patients included, higher median PP during EVT independently predicted poor functional outcome, larger FIV, MBE, and HT, but not sICH. Longer duration of PP > 50 mmHg was independently associated with poor outcome, MBE, and HT. Among other hemodynamic variables, only a >40% mean arterial pressure (MAP) drop from baseline independently predicted poor outcome. Adding median PP to the baseline multivariable model modestly increased its discriminative ability and significantly improved model fit. Conclusions: In AIS patients with proximal anterior circulation large vessel occlusion treated with EVT under general anesthesia, higher intraprocedural PP and longer exposure to elevated PP are associated with worse functional and radiological outcomes, supporting PP as a potential hemodynamic target alongside avoidance of large MAP reductions.