The RESCUE-BP is a multi-centered, prospective, randomized, open label, blinded endpoint (PROBE) phase III trial. In patients with acute ischemic stroke who have undergone endovascular treatment and achieved successful recanalization, the evaluation will compare a stratified blood pressure management strategy based on the collateral circulation status with the guideline-recommended conventional blood pressure management strategy. Within each stratum, participants will be randomized in a 1:1 ratio to either the stratified blood pressure management strategy group or the guideline-recommended conventional blood pressure management group. The goal is to determine whether this can improve good functional outcomes at 90 days (90-day Modified Rankin Scale [mRS] score 0-2).

The study consists of four visits including the day of randomization, 24±4 hours after randomization, 7±1 days after randomization and 90±7 days after randomization. Demographic information, symptoms and signs, laboratory test, neuro-imaging assessment, neurological function rating scale will be recorded during the program.

The primary outcome is the modified Rankin Scale (mRS) score of 0 to 2 at 90±7 days after randomization. The primary safety outcome is the incidence of sICH within 24±4 hours after randomization.

Inclusion Criteria:

• Age ≥ 18 years；
• Clinical diagnosis of acute ischemic stroke caused by anterior circulation large vessel occlusion (internal carotid artery or M1/M2 segment of the middle cerebral artery)；
• Received EVT (including direct EVT and bridging therapy) within 24 hours of symptom onset；
• Baseline ASPECTS score ≥ 3；
• Baseline NIHSS score ≥ 6；
• Successful recanalization achieved post-procedure (defined as expanded Thrombolysis in Cerebral Infarction [eTICI] grade ≥ 2b50);
• Two consecutive systolic blood pressure (SBP) measurements ≥ 150 mmHg within 3 hours post-recanalization (with a measurement interval of no less than 5 minutes)；
• Able to complete randomization within 3 hours post-recanalization；
• Informed consent signed by the patient or their legal representative.

Exclusion Criteria:

• Pre-stroke mRS score > 1；
• Comatose state (Glasgow Coma Scale [GCS] score < 8);
• Symptomatic intracerebral hemorrhage occurred before randomization;
• Within the past 3 months, occurrence of acute ST-segment elevation myocardial infarction (MI), acute decompensated heart failure, QTc > 500 ms, hospitalization or involuntary coronary intervention due to acute coronary syndrome, MI, or cardiac arrest; or heart failure (New York Heart Association [NYHA] class III/IV or left ventricular ejection fraction < 35%); or known history of ventricular tachycardia;
• History of severe renal insufficiency, acute renal failure, dialysis, or estimated glomerular filtration rate (eGFR) < 20 ml/min/1.72m²;
• History of severe hepatic disease, or Aspartate Aminotransferase (AST) and/or Alanine Aminotransferase (ALT) and/or Gamma-Glutamyl Transferase (GGT) ≥ 3×ULN and/or Total Bilirubin (TBIL) ≥ 2×ULN;
• Aortic dissection, cervical artery dissection, or cerebral artery dissection; unruptured aortic aneurysm or cerebral aneurysm; or known arteriovenous malformation;
• Comorbidities with a life expectancy < 6 months (e.g., malignant tumors);
• Pregnant or lactating women;
• Participation in another clinical trial within the past 30 days;
• Any clinical condition judged by the research team that might limit compliance with study procedures.

The principal researcher holds complete intellectual property rights. The entire research process and data analysis process strictly protected the information of the subjects. There is not a plan to make individual patient data (IPD) available. Sharing IPD will require IRB approval from Tiantan Hospital and other participating institutes in China.

Since the experimental group needs to perform related operations on patients, the doctors and nurses involved in the study will not be blinded for random patient allocation. However, the grouping of patients will blind neurologists and nurses responsible for conducting neurological, imaging and functional evaluations at baseline and follow-up, as well as collecting clinical outcome data. The randomization information of the patients will also blind the members of the outcome assessment committee.