Written by Denrick Cooper
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Intensive blood pressure lowering after thrombolysis in acute ischemic stroke did not significantly reduce brain swelling compared to standard BP management.
Bewitched by blood pressure? Not anymore!
In acute ischemic stroke (AIS) patients treated with thrombolysis and thrombectomy, both elevated blood pressure (BP) and rapid BP reductions have been associated with malignant cerebral edema. The original ENCHANTED trial demonstrated that intensive BP lowering reduces the risk of intracerebral hemorrhage after AIS.
This secondary analysis of ENCHANTED was a partial factorial, international, multicenter, open-label, blinded endpoint, randomized controlled trial. It enrolled 1,477 thrombolyzed AIS patients randomized to either intensive BP lowering (target systolic 130–140 mm Hg within 1 hour, maintained for 72 hours) or standard guideline BP management (target systolic <180 mm Hg). Using a 7-point radiological grading scale based on CT and MRI results, there was no statistically significant difference in cerebral edema grading between intensive and standard BP groups (adjusted odds ratio 1.06; 95% CI, 0.82–1.36; P=0.68).
This study did have its limitations. It had a predominance of patients with small infarcts, limiting applicability to those with large vessel occlusions, who are at higher risk of malignant edema. Also, the edema grading was semi-quantitative and reader-dependent; more objective volumetric or quantitative imaging methods might better characterize cerebral swelling.
How does this change my practice?
This study affirms my practice, which is a relief, given how hard tight BP control can be after thrombolysis (almost as difficult as sitting through Enchanted, the movie… and yes, yes, I did watch it). However, it raises important questions about whether patients with large vessel occlusions might benefit more from intensive BP lowering—especially before thrombectomy. This is particularly relevant for community hospitals where transfers delay treatment, making BP management during that window critical. Overall, it underscores the need for individualized BP strategies in stroke care.
Source
Effects of Intensive Blood Pressure Lowering on Brain Swelling in Thrombolyzed Acute Ischemic Stroke: The ENCHANTED Results. Stroke. 2025 Jun;56(6):1388-1395. doi: 10.1161/STROKEAHA.124.049938. Epub 2025 Apr 3. PMID: 40177745
