A Comprehensive Systematic Review of Blood Pressure Variability during Mechanical Thrombectomy under Anesthesia

Introduction: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke due to large vessel occlusion. However, optimal blood pressure (BP) management during MT under anesthesia remains uncertain, particularly regarding blood pressure variability (BPV) and its impact on clinical outcomes. This systematic review comprehensively synthesizes evidence on BPV during MT under anesthesia. Methods: We systematically screened studies from multiple databases including adult patients (≥18 years) undergoing MT under any form of anesthesia, reporting intra-procedural BPV metrics with continuous BP monitoring. Study designs included randomized controlled trials, cohort studies, case-control studies, systematic reviews, and meta-analyses with sample sizes ≥5 patients in appropriate clinical settings. Data extraction encompassed study characteristics, patient populations, anesthesia management, BP measurement methods, BPV patterns, clinical outcomes, statistical associations, and predictive factors. Results: From 104 included sources, consistent patterns emerged despite substantial methodological heterogeneity. Observational studies demonstrate associations between intraoperative BP drops and worse functional outcomes (1,2), particularly when mean arterial pressure decreases exceed 20-40% from baseline (3). Randomized trials comparing general anesthesia with procedural sedation show mixed results, with three single-center trials demonstrating equivalence or modest benefit for general anesthesia when strict protocols are applied (6,7,19). Intensive BP lowering post-thrombectomy consistently demonstrates harm (9,10), with the ENCHANTED2/MT trial showing intensive targets