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Olavarría VV. Challenging the management of blood pressure before intravenous thrombolysis in acute ischaemic stroke. Lancet Neurol 2024; 23:754-756. [PMID: 38763150 DOI: 10.1016/s1474-4422(24)00208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/21/2024]
Affiliation(s)
- Verónica V Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Clínica Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile.
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2
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Liao Z, Tian L, Wen M, Wang B, Ding K, Song Q. Safety and Efficacy of Intensive Blood Pressure-Lowering After Successful Endovascular Therapy in AIS: A Meta-Analysis. Neurologist 2024:00127893-990000000-00133. [PMID: 38767590 DOI: 10.1097/nrl.0000000000000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
OBJECTIVES Higher blood pressure has been proven to be associated with poorer functional outcomes after successful reperfusion by EVT. However, the effect of intensive blood pressure-lowering regimens in these patients remains controversial and ambiguous in clinical practice. We propose further analysis aimed at determining the effect of an intensive blood pressure-lowering regimen after EVT in AIS. METHODS The protocol registered in PROSPERO CRD42023360989. We performed a systematic search that was comprehensively executed in online databases for studies published up to June 2022. Eligibility criteria were established based on the PICOS model. The Cochrane risk of bias algorithm was used to evaluate the risk of bias. The effect models were applied to calculate the pooled ORs and CIs via Review Manager 5.4 software. RESULTS A total of 1582 citations were identified, 3 randomized clinical trials and 2 retrospective cohort studies were included. Data from 3211 patients were analyzed. We revealed that intensive blood pressure-lowering interventions could significantly reduce symptomatic intraparenchymal hemorrhage compared with standard blood pressure lowering. Nevertheless, favorable functional outcome, poor outcome, all-cause mortality within 3 months and intraparenchymal hemorrhage in 24 hours showed no significant differences. Subgroup analysis revealed the variability of systolic blood pressure within 24 hours after EVT was not associated with odds of poor outcome and intraparenchymal hemorrhage. CONCLUSIONS Based on the current evidence, intensive blood pressure-lowering regimen was superior to standard blood pressure-lowering regimen for a reduced risk of symptomatic intraparenchymal hemorrhage in AIS patients treated with EVT, but there was no statistically significant difference found between the 2 regimens for the other outcomes.
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Affiliation(s)
- Zhouzan Liao
- Department of Neurology, Youxian People's Hospital, Zhuzhou
| | - Li Tian
- Functional Department, Hunan University of Medicine General Hospital, Huaihua
| | - Ming Wen
- Department of Neurology, Youxian People's Hospital, Zhuzhou
| | - Bing Wang
- Department of Neurology, Youxian People's Hospital, Zhuzhou
| | - Kai Ding
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Guilin Medical University, Guilin
- Department of Geriatrics, Hunan University of Medicine General Hospital, Huaihua, China
| | - Qionglin Song
- Functional Department, Hunan University of Medicine General Hospital, Huaihua
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3
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Parvathy G, Kamaraj B, Sah B, Maheshwari A, Alexander A, Dixit V, Mumtaz H, Saqib M. Emerging artificial intelligence-aided diagnosis and management methods for ischemic strokes and vascular occlusions: A comprehensive review. World Neurosurg X 2024; 22:100303. [PMID: 38510336 PMCID: PMC10951088 DOI: 10.1016/j.wnsx.2024.100303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Abstract
Large-vessel occlusion (LVO) stroke is a promising field for the use of AI, especially machine learning (ML) because optimal results are highly dependent on timely diagnosis, communication, and treatment. In order to better understand the current state of artificial intelligence (AI) in relation to LVO strokes, its efficacy, and potential future applications, we searched relevant literature to perform a comprehensive evaluation of the topic. The databases PubMed, Embase, and Scopus were extensively searched for this review. Studies were then screened using title and abstract criteria and duplicate studies were excluded. By using pre-established inclusion and exclusion criteria, it was decided whether or not to include full-text papers in the final analysis. The studies were analyzed, and the relevant information was retrieved. In recognizing LVO on computed tomography, ML approaches were very accurate. There is a shortage of AI applications for thrombectomy patient selection, despite the fact that certain research accurately evaluates individual patient eligibility for endovascular therapy. Machine learning algorithms may reasonably predict clinical and angiographic outcomes as well as associated factors. AI has shown promise in the diagnosis and treatment of people who have just suffered a stroke. However, the usefulness of AI in management and forecasting remains restricted, necessitating more studies into machine learning applications that can guide decision making in the future.
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4
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Du L, Zhang Y, Li X, Liu C, Li Z, Zhou J, Liu Y. Blood pressure excursion on admission and intravenous thrombolysis in ischemic stroke. J Hypertens 2023; 41:1265-1270. [PMID: 37199548 PMCID: PMC10328519 DOI: 10.1097/hjh.0000000000003456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/30/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Blood pressure (BP) excursion on admission was common in patients with acute ischemic stroke, but its influence on thrombolysis effect was not fully evaluated. METHODS Patients with acute ischemic stroke who received thrombolysis without subsequent thrombectomy were included. Admission BP excursion was defined as higher than 185/110 mmHg. Multivariate logistic regression analysis was used to evaluate the relationship between admission BP excursion and poor outcome as well as hemorrhage rates and mortality. Poor outcome was defined as a 90-day modified Rankin Scale score 3-6. Subgroup analysis was performed according to stroke severity, which was assessed by the National Institutes of Health Stroke Scale (NIHSS) score, and hypertension status. RESULTS A total of 633 patients were enrolled and 240 participants (37.9%) had admission BP excursion. Admission BP excursion was associated with poor outcome [adjusted odds ratio (OR) 0.64, 95% confidence interval 0.42-0.99, P = 0.046]. No significant difference was found regarding hemorrhage rates or mortality between patients with and without admission BP excursion. In subgroup analysis, admission BP excursion was related to poor outcome in patients with NIHSS score at least 7 (adjusted OR 1.89, 95% confidence interval 1.03-3.45, P = 0.038), but not in patients with NIHSS score less than 7 ( P for interaction <0.001). CONCLUSION Admission BP excursion above the guideline thresholds did not increase postthrombolysis hemorrhage risk or mortality, but was associated with poor outcome, especially in patients with severe stroke.
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Affiliation(s)
| | - Yuqiao Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaohui Li
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chengfang Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhongyuan Li
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yukai Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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5
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Manolis AJ, Kallistratos MS, Camafort M, Coca A. How low should blood pressure be in patients with chronic coronary and cerebrovascular diseases. Eur J Intern Med 2023; 109:22-29. [PMID: 36631307 DOI: 10.1016/j.ejim.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Abstract
Over the last three decades, there are an increasing number of investigators and meta-analyses focusing on the fact that lowering blood pressure levels below a critical point is no longer beneficial and possibly even deleterious. In recent years, several trials and meta-analyses assessing intensive blood pressure (BP) lowering found that intensive treatment and lower blood pressure levels are associated with a reduction in CV events and mortality. However, a careful examination of the results shows that current data are not easily applicable to the general hypertensive population. In addition, recommendations of different guidelines since 2017 so far suggest different BP levels regarding the systolic and diastolic thresholds to be achieved and maintained, particularly in specific clinical situations such as patients with coronary artery disease and stroke. The challenge is to better define the limits of intervention and to define phenotypes of patients who are particularly vulnerable to over-aggressive lowering of blood pressure. This article reviews the evidence, controversies and current state of knowledge regarding intensive BP lowering and the lower thresholds of BP to be achieved in patients with chronic coronary or cerebrovascular diseases.
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Affiliation(s)
- A J Manolis
- Cardiology Department, Metropolitan Hospital, Piraeus, Greece
| | | | - M Camafort
- Hypertension and Vascular Risk Unit, Department of Internal Medicine. Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - A Coca
- Hypertension and Vascular Risk Unit, Department of Internal Medicine. Hospital Clínic, University of Barcelona, Barcelona, Spain
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6
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Kolahchi Z, Rahimian N, Momtazmanesh S, Hamidianjahromi A, Shahjouei S, Mowla A. Direct Mechanical Thrombectomy Versus Prior Bridging Intravenous Thrombolysis in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. LIFE (BASEL, SWITZERLAND) 2023; 13:life13010185. [PMID: 36676135 PMCID: PMC9863165 DOI: 10.3390/life13010185] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/15/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND The current guideline recommends using an intravenous tissue-type plasminogen activator (IV tPA) prior to mechanical thrombectomy (MT) in eligible acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). Some recent studies found no significant differences in the long-term functional outcomes between bridging therapy (BT, i.e., IV tPA prior to MT) and direct MT (dMT). METHODS We conducted a systematic review and meta-analysis to compare the safety and functional outcomes between BT and dMT in AIS patients with ELVO who were eligible for IV tPA administration. Based on the ELVO location, patients were categorized as the anterior group (occlusion of the anterior circulation), or the combined group (occlusion of the anterior and/or posterior circulation). A subgroup analysis was performed based on the study type, i.e., RCT and non-RCT. RESULTS Thirteen studies (3985 patients) matched the eligibility criteria. Comparing the BT and dMT groups, no significant differences in terms of mortality and good functional outcome were observed at 90 days. Symptomatic intracranial hemorrhagic (sICH) events were more frequent in BT patients in the combined group (OR = 0.73, p = 0.02); this result remained significant only in the non-RCT subgroup (OR = 0.67, p = 0.03). The RCT subgroup had a significantly higher rate of successful revascularization in BT patients (OR = 0.73, p = 0.02). CONCLUSIONS Our meta-analysis uncovered no significant differences in functional outcome and mortality rate at 90 days between dMT and BT in patients with AIS who had ELVO. Although BT performed better in terms of successful recanalization rate, there is a risk of increased sICH rate in this group.
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Affiliation(s)
- Zahra Kolahchi
- School of Medicine, Tehran University of Medical Sciences, Tehran 1417613151, Iran
| | - Nasrin Rahimian
- Department of Neurology, Creighton University Medical Center, Omaha, NE 68124, USA
| | - Sara Momtazmanesh
- School of Medicine, Tehran University of Medical Sciences, Tehran 1417613151, Iran
| | - Anahid Hamidianjahromi
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Shima Shahjouei
- Department of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Correspondence: ; Tel.: +323-409-7422; Fax: +323-226-7833
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7
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Psychogios M, Brehm A, López-Cancio E, Marco De Marchis G, Meseguer E, Katsanos AH, Kremer C, Sporns P, Zedde M, Kobayashi A, Caroff J, Bos D, Lémeret S, Lal A, Arenillas JF. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease. Eur Stroke J 2022; 7:III-IV. [PMID: 36082254 PMCID: PMC9446330 DOI: 10.1177/23969873221099715] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/22/2022] [Indexed: 07/22/2023] Open
Abstract
The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of patients with intracranial atherosclerotic disease (ICAD). The guidelines were prepared following the Standard Operational Procedure of the European Stroke Organisation guidelines and according to GRADE methodology. ICAD represents a major cause of ischemic stroke worldwide, and patients affected by this condition are exposed to a high risk for future strokes and other major cardiovascular events, despite best medical therapy available. We identified 11 relevant clinical problems affecting ICAD patients and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions. The first two questions refer to the asymptomatic stage of the disease, which is being increasingly detected thanks to the routine use of noninvasive vascular imaging. We were not able to provide evidence-based recommendations regarding the optimal detection strategy and management of asymptomatic ICAD, and further research in the field is encouraged as subclinical ICAD may represent a big opportunity to improve primary stroke prevention. The second block of PICOs (3-5) is dedicated to the management of acute large vessel occlusion (LVO) ischemic stroke caused by ICAD, a clinical presentation of this disease that is becoming increasingly relevant and problematic, since it is associated with more refractory endovascular reperfusion procedures. An operational definition of probable ICAD-related LVO is proposed in the guideline. Despite the challenging context, no dedicated randomized clinical trials (RCTs) were identified, and therefore the guideline can only provide with suggestions derived from observational studies and our expert consensus, such as the escalated use of glycoprotein IIb-IIIa inhibitors and angioplasty/stenting in cases of refractory thrombectomies due to underlying ICAD. The last block of PICOs is devoted to the secondary prevention of patients with symptomatic ICAD. Moderate-level evidence was found to recommend against the use of oral anticoagulation as preferred antithrombotic drug, in favor of antiplatelets. Low-level evidence based our recommendation in favor of double antiplatelet as the antithrombotic treatment of choice in symptomatic ICAD patients, which we suggest to maintain during 90 days as per our expert consensus. Endovascular therapy with intracranial angioplasty and or stenting is not recommended as a treatment of first choice in high-grade symptomatic ICAD (moderate-level evidence). Regarding neurosurgical interventions, the available evidence does not support their use as front line therapies in patients with high-grade ICAD. There is not enough evidence as to provide any specific recommendation regarding the use of remote ischemic conditioning in ICAD patients, and further RCTs are needed to shed light on the utility of this promising therapy. Finally, we dedicate the last PICO to the importance of aggressive vascular risk factor management in ICAD, although the evidence derived from RCTs specifically addressing this question is still scarce.
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Affiliation(s)
- Marios Psychogios
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
| | - Elena López-Cancio
- Department of Neurology, Hospital
Universitario Central de Asturias, Oviedo, Spain
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Elena Meseguer
- Department of Neurology and Stroke
Center, Assistance Publique Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster
University and Population Health Research Institute, Hamilton, ON, Canada
| | - Christine Kremer
- Department of Neurology, Skåne
University Hospital, Malmö, Department of Clinical Sciences Lund University, Lund,
Sweden
| | - Peter Sporns
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology,
University Clinic Hamburg Eppendorf, Hamburg, Germany
| | - Marialuisa Zedde
- Neurology Unit, Department of
Neuromotor Physiology, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio
Emilia, Italy
- Neurology Unit, Stroke Unit, Azienda
Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy
| | - Adam Kobayashi
- Department of Pharmacology and
Clinical Pharmacology, Institute of Medical Sciences, Faculty of Medicine –
Collegium Medicum Cardinal Stefan Wyszynski University in Warsaw, Poland
- Department of Neurology and Stroke
Unit, Mazovian Voivodeship Hospital in Siedlce, Poland
| | - Jildaz Caroff
- Department of Interventional
Neuroradiology – NEURI Brain Vascular Center, Bicêtre Hospital, Assistance Publique
Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Daniel Bos
- Department of Radiology and Nuclear
Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus
MC, Rotterdam, The Netherlands
| | | | - Avtar Lal
- European Stroke Organisation, Basel,
Switzerland
| | - Juan F Arenillas
- Stroke Program, Department of
Neurology, Hospital Clínico Universitario de Valladolid, Spain
- Clinical Neurosciences Research
Group, Department of Medicine, University of Valladolid, Spain
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8
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Robinson TG, Minhas JS, Miller J. Review of major trials of acute blood pressure management in stroke. J Cereb Blood Flow Metab 2022; 42:404-410. [PMID: 33761781 PMCID: PMC8851668 DOI: 10.1177/0271678x211004310] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 02/02/2023]
Abstract
Over the last two decades, there have been a number of major landmark clinical trials, classified as "major" as they sought to address clear clinical practice driven questions, in a pragmatic yet robust trial design, using a large powered sample size (n > 1000), in order to help improve patient outcome through informing guidelines. A commonality across all stroke sub-types included in these trials is the tendency to acute hypertensive crises within the acute stroke period. This phenomenon is associated with greater stroke complications and worsened overall prognosis. Multiple trials have attempted to address the issue of acute blood pressure management during the acute stroke period, with consideration for timing, magnitude of lowering, agent and relationship to other interventions. This review will consider the major clinical trials performed in ischaemic and haemorrhagic stroke that test the hypothesis that acute BP reduction improves clinical outcomes.
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Affiliation(s)
- Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester,
Leicester, UK
- National Institute for Health Research Leicester Biomedical
Research Centre, The Glenfield Hospital, Leicester, UK
| | - Jatinder S Minhas
- Department of Cardiovascular Sciences, University of Leicester,
Leicester, UK
- National Institute for Health Research Leicester Biomedical
Research Centre, The Glenfield Hospital, Leicester, UK
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital and Wayne
State University, Detroit, MI, USA
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9
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Nicholls JK, Ince J, Minhas JS, Chung EML. Emerging Detection Techniques for Large Vessel Occlusion Stroke: A Scoping Review. Front Neurol 2022; 12:780324. [PMID: 35095726 PMCID: PMC8796731 DOI: 10.3389/fneur.2021.780324] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Large vessel occlusion (LVO) is the obstruction of large, proximal cerebral arteries and can account for up to 46% of acute ischaemic stroke (AIS) when both the A2 and P2 segments are included (from the anterior and posterior cerebral arteries). It is of paramount importance that LVO is promptly recognised to provide timely and effective acute stroke management. This review aims to scope recent literature to identify new emerging detection techniques for LVO. As a good comparator throughout this review, the commonly used National Institutes of Health Stroke Scale (NIHSS), at a cut-off of ≥11, has been reported to have a sensitivity of 86% and a specificity of 60% for LVO. Methods: Four electronic databases (Medline via OVID, CINAHL, Scopus, and Web of Science), and grey literature using OpenGrey, were systematically searched for published literature investigating developments in detection methods for LVO, reported from 2015 to 2021. The protocol for the search was published with the Open Science Framework (10.17605/OSF.IO/A98KN). Two independent researchers screened the titles, abstracts, and full texts of the articles, assessing their eligibility for inclusion. Results: The search identified 5,082 articles, in which 2,265 articles were screened to assess their eligibility. Sixty-two studies remained following full-text screening. LVO detection techniques were categorised into 5 groups: stroke scales (n = 30), imaging and physiological methods (n = 15), algorithmic and machine learning approaches (n = 9), physical symptoms (n = 5), and biomarkers (n = 3). Conclusions: This scoping review has explored literature on novel and advancements in pre-existing detection methods for LVO. The results of this review highlight LVO detection techniques, such as stroke scales and biomarkers, with good sensitivity and specificity performance, whilst also showing advancements to support existing LVO confirmatory methods, such as neuroimaging.
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Affiliation(s)
- Jennifer K. Nicholls
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Medical Physics, University Hospitals of Leicester, NHS Trust, Leicester, United Kingdom
| | - Jonathan Ince
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Jatinder S. Minhas
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Emma M. L. Chung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Medical Physics, University Hospitals of Leicester, NHS Trust, Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
- School of Life Course Sciences, King's College London, London, United Kingdom
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10
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Katsanos AH, Malhotra K, Ahmed N, Seitidis G, Mistry EA, Mavridis D, Kim JT, Veroniki A, Maier I, Matusevicius M, Khatri P, Anadani M, Goyal N, Arthur AS, Sarraj A, Yaghi S, Shoamanesh A, Catanese L, Kantzanou M, Psaltopoulou T, Rentzos A, Psychogios M, Van Adel B, Spiotta AM, Sandset EC, de Havenon A, Alexandrov AV, Petersen NH, Tsivgoulis G. Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis. Neurology 2021; 98:e291-e301. [PMID: 34772799 DOI: 10.1212/wnl.0000000000013049] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). METHODS A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model. RESULTS A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission: 16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT. CONCLUSION Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada .,Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Georgios Seitidis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Paris Descartes University, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Argie Veroniki
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Ilko Maier
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Marius Matusevicius
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mohammad Anadani
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Amrou Sarraj
- Department of Neurology, UT Houston, Houston, Texas, USA
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Luciana Catanese
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Maria Kantzanou
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rentzos
- Diagnostic and Interventional Neuroradiology, Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marios Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Brian Van Adel
- Division of Neurology, Neurosurgery, and Diagnostic Imaging, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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11
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Beishon LC, Minhas JS. Cerebral Autoregulation and Neurovascular Coupling in Acute and Chronic Stroke. Front Neurol 2021; 12:720770. [PMID: 34539560 PMCID: PMC8446264 DOI: 10.3389/fneur.2021.720770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/11/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lucy C. Beishon
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Jatinder S. Minhas
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
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12
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Zhou Z, Xia C, Mair G, Delcourt C, Yoshimura S, Liu X, Chen Z, Malavera A, Carcel C, Chen X, Wang X, Al-Shahi Salman R, Robinson TG, Lindley RI, Chalmers J, Wardlaw JM, Parsons MW, Demchuk AM, Anderson CS. Thrombolysis outcomes according to arterial characteristics of acute ischemic stroke by alteplase dose and blood pressure target. Int J Stroke 2021; 17:566-575. [PMID: 34096413 DOI: 10.1177/17474930211025436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND We explored the influence of low-dose intravenous alteplase and intensive blood pressure lowering on outcomes of acute ischemic stroke according to status/location of vascular obstruction in participants of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). METHODS ENCHANTED was a multicenter, quasi-factorial, randomized trial to determine efficacy and safety of low- versus standard-dose intravenous alteplase and intensive- versus guideline-recommended blood pressure lowering in acute ischemic stroke patients. In those who had baseline computed tomography or magnetic resonance imaging angiography, the degree of vascular occlusion was grouped according to being no (NVO), medium (MVO), or large (LVO). Logistic regression models were used to determine 90-day outcomes (modified Rankin scale [mRS] shift [primary], other mRS cut-scores, intracranial hemorrhage, early neurologic deterioration, and recanalization) by vascular obstruction status/site. Heterogeneity in associations for outcomes across subgroups was estimated by adding an interaction term to the models. RESULTS There were 940 participants: 607 in alteplase arm only, 243 in blood pressure arm only, and 90 assigned to both arms. Compared to the NVO group, functional outcome was worse in LVO (mRS shift, adjusted OR [95% CI] 2.13 [1.56-2.90]) but comparable in MVO (1.34 [0.96-1.88]) groups. There were no differences in associations of alteplase dose or blood pressure lowering and outcomes across NVO/MVO/LVO groups (mRS shift: low versus standard alteplase dose 0.84 [0.54-1.30]/0.48 [0.25-0.91]/0.99 [0.75-2.09], Pinteraction = 0.28; intensive versus standard blood pressure lowering 1.32 [0.74-2.38]/0.78 [0.31-1.94]/1.24 [0.64-2.41], Pinteraction = 0.41), except for a borderline significant difference for intensive blood pressure lowering and increased early neurologic deterioration (0.63 [0.14-2.72]/0.17 [0.02-1.47]/2.69 [0.90-8.04], Pinteraction = 0.05). CONCLUSIONS Functional outcome by dose of alteplase or intensity of blood pressure lowering is not modified by vascular obstruction status/site according to analyses from ENCHANTED, although these results are compromised by low statistical power.Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifiers: NCT01422616.
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Affiliation(s)
- Zien Zhou
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Radiology, Ren Ji Hospital, School of Medicine, 12474Shanghai Jiao Tong University, Shanghai, PR China
| | - Chao Xia
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Neurosurgery, West China Hospital, 12530Sichuan University, Chengdu, PR China
| | - Grant Mair
- Edinburgh Imaging and Centre for Clinical Brain Sciences, 3124University of Edinburgh, Edinburgh, UK
| | - Candice Delcourt
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, Australia
| | - Sohei Yoshimura
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Xiaosheng Liu
- Department of Nuclear Medicine, 12478Fudan University Shanghai Cancer Center, Shanghai, PR China
| | - Zengai Chen
- Department of Radiology, Ren Ji Hospital, School of Medicine, 12474Shanghai Jiao Tong University, Shanghai, PR China
| | - Alejandra Malavera
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia
| | - Cheryl Carcel
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Xiaoying Chen
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Xia Wang
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia
| | | | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Center, 4488University of Leicester, Leicester, UK
| | | | - John Chalmers
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia
| | - Joanna M Wardlaw
- Edinburgh Imaging and Centre for Clinical Brain Sciences, 3124University of Edinburgh, Edinburgh, UK.,UK Dementia Research Institute, 3124University of Edinburgh, Edinburgh, UK
| | - Mark W Parsons
- South Western Clinical School, 7800University of New South Wales, Sydney, Australia.,Melbourne Brain Centre, Royal Melbourne Hospital, Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, 157742Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Radiology, 157742Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Craig S Anderson
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia.,The George Institute China at Peking University Health Science Center, Beijing, PR China
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13
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Sandset EC, Anderson CS, Bath PM, Christensen H, Fischer U, Gąsecki D, Lal A, Manning LS, Sacco S, Steiner T, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J 2021; 6:XLVIII-LXXXIX. [PMID: 34780578 PMCID: PMC8370078 DOI: 10.1177/23969873211012133] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/05/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke.The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
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Affiliation(s)
- Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- The George Institute China at Peking University Health Science Center, Beijing, PR China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital & University of Copenhagen, Copenhagen, Denmark
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dariusz Gąsecki
- Department of Adult Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - Avtar Lal
- Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Lisa S Manning
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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14
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Nogueira RC, Beishon L, Bor-Seng-Shu E, Panerai RB, Robinson TG. Cerebral Autoregulation in Ischemic Stroke: From Pathophysiology to Clinical Concepts. Brain Sci 2021; 11:511. [PMID: 33923721 PMCID: PMC8073938 DOI: 10.3390/brainsci11040511] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/02/2021] [Accepted: 04/09/2021] [Indexed: 11/17/2022] Open
Abstract
Ischemic stroke (IS) is one of the most impacting diseases in the world. In the last decades, new therapies have been introduced to improve outcomes after IS, most of them aiming for recanalization of the occluded vessel. However, despite this advance, there are still a large number of patients that remain disabled. One interesting possible therapeutic approach would be interventions guided by cerebral hemodynamic parameters such as dynamic cerebral autoregulation (dCA). Supportive hemodynamic therapies aiming to optimize perfusion in the ischemic area could protect the brain and may even extend the therapeutic window for reperfusion therapies. However, the knowledge of how to implement these therapies in the complex pathophysiology of brain ischemia is challenging and still not fully understood. This comprehensive review will focus on the state of the art in this promising area with emphasis on the following aspects: (1) pathophysiology of CA in the ischemic process; (2) methodology used to evaluate CA in IS; (3) CA studies in IS patients; (4) potential non-reperfusion therapies for IS patients based on the CA concept; and (5) the impact of common IS-associated comorbidities and phenotype on CA status. The review also points to the gaps existing in the current research to be further explored in future trials.
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Affiliation(s)
- Ricardo C. Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo 01246-904, Brazil;
- Department of Neurology, Hospital Nove de Julho, São Paulo 01409-002, Brazil
| | - Lucy Beishon
- Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; (L.B.); (R.B.P.); (T.G.R.)
| | - Edson Bor-Seng-Shu
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo 01246-904, Brazil;
| | - Ronney B. Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; (L.B.); (R.B.P.); (T.G.R.)
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University of Leicester, Leicester LE5 4PW, UK
| | - Thompson G. Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; (L.B.); (R.B.P.); (T.G.R.)
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University of Leicester, Leicester LE5 4PW, UK
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15
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Zhou Z, Xia C, Carcel C, Yoshimura S, Wang X, Delcourt C, Malavera A, Chen X, Mair G, Woodward M, Chalmers J, Demchuk AM, Lindley RI, Robinson TG, Parsons MW, Wardlaw JM, Anderson CS. Intensive versus guideline-recommended blood pressure reduction in acute lacunar stroke with intravenous thrombolysis therapy: The ENCHANTED trial. Eur J Neurol 2020; 28:783-793. [PMID: 33069172 DOI: 10.1111/ene.14598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/14/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE This was an investigation of the differential effects of early intensive versus guideline-recommended blood pressure (BP) lowering between lacunar and non-lacunar acute ischaemic stroke (AIS) in the BP arm of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). METHODS In 1,632 participants classified as having definite or probable lacunar (n = 454 [27.8%]) or non-lacunar AIS according to pre-specified definitions based upon clinical and adjudicated imaging findings, mean BP changes over days 0-7 were plotted, and systolic BP differences by treatment between subgroups were estimated in generalized linear models. Logistic regression models were used to estimate the BP treatment effects on 90-day outcomes (primary, an ordinal shift of modified Rankin scale scores) across lacunar and non-lacunar AIS after adjustment for baseline covariables. RESULTS Most baseline characteristics, acute BP and other management differed between lacunar and non-lacunar AIS, but mean systolic BP differences by treatment were comparable at each time point (all pinteraction > 0.12) and over 24 h post-randomization (-5.5, 95% CI -6.5, -4.4 mmHg in lacunar AIS vs. -5.6, 95% CI -6.3, -4.8 mmHg in non-lacunar AIS, pinteraction = 0.93). The neutral effect of intensive BP lowering on functional outcome and the beneficial effect on intracranial haemorrhage were similar for the two subgroups (all pinteraction > 0.19). CONCLUSIONS There were no differences in the treatment effect of early intensive versus guideline-recommended BP lowering across lacunar and non-lacunar AIS.
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Affiliation(s)
- Zien Zhou
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chao Xia
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Sohei Yoshimura
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Alejandra Malavera
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Grant Mair
- Division of Neuroimaging Sciences, Edinburgh Imaging and Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - John Chalmers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Richard I Lindley
- The George Institute for Global Health and University of Sydney, Sydney, NSW, Australia
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Center, University of Leicester, Leicester, UK
| | - Mark W Parsons
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Medicine, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Vic, Australia
| | - Joanna M Wardlaw
- Division of Neuroimaging Sciences, Edinburgh Imaging and Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia.,The George Institute China at Peking University Health Science Center, Beijing, China
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