Prognostic Modeling Based on Post–Endovascular Thrombectomy Systolic Blood Pressure Trajectories Using Explainable Artificial Intelligence: A Secondary Analysis of the OPTIMAL-BP Trial

Abstract

Blood pressure (BP) management following successful reperfusion after endovascular thrombectomy (EVT) is critical in achieving favorable clinical outcomes. Individualized BP management using predictive modeling by machine learning may further improve prediction of functional outcomes. This study was a retrospective analysis of data from the Outcome in Patients Treated with Intra-Arterial Thrombectomy–Optimal Blood Pressure Control (OPTIMAL-BP) trial, a randomized controlled trial comparing between intensive and conventional BP management during the 24 h after successful recanalization by EVT from June 18, 2020, to November 28, 2022. The trial was conducted across 19 centers in South Korea. Machine learning models were developed to predict functional independence (90-day modified Rankin Scale 0 to 2). Model performance was compared between clinical variables only and systolic blood pressure (SBP) metrics in addition to clinical variables. In addition, the Shapley additive explanations (SHAP) analysis was performed to provide model explanation and understand the importance of SBP metrics. A total of 288 patients (61.1% men, median age 75 years [interquartile range, 65–81]) were included. Among the six algorithms, the deep neural network model incorporating SBP metrics performed best on validation, achieving an area under the curve of 0.86 (95% confidence interval, 0.76–0.92) which was significantly better than the model using only clinical variables (area under the curve 0.80 [95% confidence interval, 0.69–0.88], P =.037). Among SBP metrics, SHAP analysis identified time rate of SBP and minimum SBP as important features, with time rate showing greater influence in the intensive group and minimum SBP in the conventional group. Integrating SBP metrics with clinical variables significantly improved machine learning performance in predicting functional outcomes after successful EVT. Explainable artificial intelligence (AI) identified time rate and minimum SBP as key predictors of outcome. Trial Registration Information: ClinicalTrials.gov (NCT04205305; registered December 17, 2019). © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2026.