Abstract: Blood pressure management strategies after endovascular thrombectomy (EVT) in patients with acute ischemic stroke are a current research focus. Multiple randomized controlled trials, including ENCHANTED-2/MT and OPTIMAL-BP, as well as meta-analyses, have consistently shown that the routine use of intensive blood pressure-lowering strategies after EVT does not improve 90-day functional outcomes in patients with acute ischemic stroke, and may even be harmful by aggravating hypoperfusion. This article systematically describes the pathophysiological basis of blood pressure management after EVT, including impaired cerebral blood flow autoregulation, reperfusion injury and futile reperfusion, and the compensatory role of collateral circulation. Through a systematic interpretation of key trials and their subgroup analyses, this article reveals heterogeneity in responses to blood pressure management among different subgroups. For example, patients with poor collateral circulation, intracranial atherosclerotic stenosis, or incomplete recanalization are more sensitive to hypoperfusion, and the harm caused by intensive blood pressure lowering is particularly significant. Based on the above evidence, this article proposes an individualized management pathway centered on rapid assessment, risk stratification, and dynamic adjustment. Patients are classified into three categories: hypoperfusion risk-dominant type, hyperperfusion risk-dominant type, and intermediate type, and a stratified management model with different initial targets is established. Future research should further focus on validation in specific subgroups, continuous monitoring technologies, and optimization of management quality.