Blood pressure goals after mechanical thrombectomy: a moving target

Intra-arterial tenecteplase during thrombectomy for acute stroke (BRETIS-TNK II): rationale and design

“…To minimise the risk of intracranial haemorrhage (ICH), several strategies are in place: (1) Aside from procedurally administered heparinised saline (a continuous drip of 2000 IU heparin in 1000 mL saline into femoral artery sheaths), which will be used if intravenous thrombolysis was not given before EVT, intravenous heparin is prohibited until after the 24 hours after EVT when neuroimaging has been performed; (2) Blood pressure will be tightly controlled to less than 185/110 mm Hg during the first 24 hours. If TICI >2 b reperfusion is achieved and the systolic blood pressure is persistently above 140 mm Hg, a blood pressure of 120–160/70–90 mm Hg would be targeted by continuous monitoring after EVT16; (3) Blood glucose level will be controlled to less than 160 mg/dL; (4) If contrast extravasation occurs during the procedure which may indicate active bleeding, the TNK infusion will be stopped immediately; (5) If ICAD-LVO is highly suspected and rescue balloon angioplasty and/or stenting will be performed, the dose of intra-arterial TNK will be reduced to half of the recommended dose, or stop, as determined by the local investigator and (6) If there is a concern for change in the patient’s neurological condition, a CT scan (flat panel CT in the angio suite permitted) will be performed to rule out haemorrhage and if present, TNK will be immediately stopped. Hypotension and hypovolaemia will be corrected or avoided according to current guidelines 14 15.…”

Acute and Interventional Treatments

“…Ongoing studies (https://www.clinicaltrials.gov; Unique identifiers: NCT04205305, NCT04116112, NCT04775147) will further refine blood pressure targets after thrombectomy. 16…”