By Isabella Colonna
For January, we have selected Yang P, Song L, Zhang Y, Zhang X, Chen X, Li Y, Sun L, Wan Y, Billot L, Li Q, Ren X, Shen H, Zhang L, Li Z, Xing P, Zhang Y, Zhang P, Hua W, Shen F, Zhou Y, Tian B, Chen W, Han H, Zhang L, Xu C, Li T, Peng Y, Yue X, Chen S, Wen C, Wan S, Yin C, Wei M, Shu H, Nan G, Liu S, Liu W, Cai Y, Sui Y, Chen M, Zhou Y, Zuo Q, Dai D, Zhao R, Li Q, Huang Q, Xu Y, Deng B, Wu T, Lu J, Wang X, Parsons MW, Butcher K, Campbell B, Robinson TG, Goyal M, Dippel D, Roos Y, Majoie C, Wang L, Wang Y, Liu J, Anderson CS; ENCHANTED2/MT Investigators. Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet. 2022 Nov 5;400(10363):1585-1596. doi: 10.1016/S0140-6736(22)01882-7. Epub 2022 Oct 28. Erratum in: Lancet. 2022 Dec 3;400(10367):1926. PMID: 36341753.
Endovascular thrombectomy, associated or not with intravenous thrombolysis, is currently the standard treatment of acute stroke due to intracranial large-vessel occlusion. Despite the achievement of a good level of reperfusion, the grade of functional recovery still varies among patients and the risk of reperfusion injury remains high.
The management of blood pressure might play an important role in the prevention of reperfusion injury. So far, there are insufficient data that could permit to identify the optimal blood pressure values to target after thrombectomy.
This paper reports the results of the ENCHANTED 2/MT trial, a multicentre, open-label, blinded-endpoint, randomised controlled phase-3 trial performed in 44 Chinese hospitals, aiming to compare more intensive (target systolic blood pressure <120 mm Hg) with less intensive (target systolic blood pressure 140-180 mmHg) blood pressure management after successful endovascular thrombectomy (eTICI score 2-3).
After screening for eligibility, 407 and 409 patients were assigned to the more intensive and to the less intensive treatment groups, respectively. Patients in the more intensive treatment group presented worse functional recovery at 90 days, higher incidence of death and neurological deterioration at 7 and 90 days, as well as poorer health-related quality of life. There were no significant differences between groups in the incidence of symptomatic intracranial bleeding and of serious adverse events, in all-cause mortality and in the recurrence of ischaemic stroke events.
The results of this trial show that a more intensive blood pressure management after endovascular thrombectomy (systolic blood pressure <120 mmHg) is associated with worse functional outcome, suggesting that a more intense blood pressure lowering may reduce the perfusion of cerebral microcirculation. Further studies are still needed in order to define the optimal systolic blood pressure to target in patients who underwent endovascular thrombectomy.