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Chen M, Sauer LD, Herwig M, Jesser J, Kieser M, Potreck A, Möhlenbruch M, Ringleb PA, Schönenberger S. Association of intraprocedural near admission-level blood pressure with functional outcome in stroke patients treated with mechanical thrombectomy. Neurol Res Pract 2024; 6:46. [PMID: 39354580 PMCID: PMC11443703 DOI: 10.1186/s42466-024-00345-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Accepted: 09/24/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND Optimal blood pressure management during endovascular stroke treatment is not certain. We hypothesized that time or proportion of intraprocedural systolic blood pressure spent in a range around admission blood pressure might be associated with better clinical outcome. METHODS We conducted a retrospective observational study at a single center at a university hospital, which included patients from August 2018 to September 2020 suffering from acute ischemic stroke with anterior circulation vessel occlusion and treated with endovascular therapy. Time and proportion of procedure time where systolic blood pressure (SBP) was near the baseline SBP on admission (bSBP) were used as exposure variables. The primary outcome was the occurrence of mRS score 0-2 three months after stroke. The primary analysis was performed by fitting a logistic regression model adjusted for baseline NIHSS, pre-stroke mRS, mTICI score, intubation, age and sex. RESULTS We included 589 patients in the analysis. Mean (SD) age was 76 (12) years, 315 were women (53%) and mean (SD) NIHSS score at admission was 15 (7.5). Mean (SD) bSBP was 167 (28) mmHg and mean (SD) intraprocedural SBP was 147 (21) mmHg. The proportion of time where intraprocedural SBP was in range of bSBP ± 20% was associated with a slightly higher odds of achieving favorable outcome (adjusted OR, 1.007; 95% CI, 1.0003-1.013). CONCLUSION A higher proportion of intraprocedural time with systolic blood pressure in range of ± 20% of the admission level is associated with higher odds of favorable functional outcome. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Min Chen
- Department of Neurology, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany.
| | - Lukas Daniel Sauer
- Institute of Medical Biometry, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Mika Herwig
- Department of Neurology, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
| | - Jessica Jesser
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Arne Potreck
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
| | - Peter Arthur Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
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2
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Dong X, Liu Y, Chu X, Yu E, Jia X, Ji X, Wu C. Blood pressure management after endovascular thrombectomy: Insights of recent randomized controlled trials. CNS Neurosci Ther 2024; 30:e14907. [PMID: 39118229 PMCID: PMC11310089 DOI: 10.1111/cns.14907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 07/18/2024] [Accepted: 07/23/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND The ideal blood pressure (BP) target in patients who undergo endovascular thrombectomy (EVT) with successful reperfusion is uncertain. Observational studies show that elevated BP during this period is associated with a higher risk of intracranial hemorrhage (ICH) and worse clinical outcomes. Several randomized controlled trials (RCTs) have explored whether intensive BP lowering improves clinical outcomes in these patients. AIMS This review aims to summarize the recent RCTs that compare intensive and conventional BP management strategies following EVT and discuss the innovative directions to improve. RESULT The recently published RCTs failed to demonstrate the benefit of intensive BP control on the functional outcome and decreasing the risk of ICH. The complex mechanism in cerebral blood flow regulation and the inappropriate BP range chosen in RCTs may be the reasons behind the inconsistent results between observational studies and RCTs. Individualized BP management, reducing BP variability, and multi-stage BP management should be paid more attention in future exploration. CONCLUSION Intensive BP target did not improve clinical outcomes after successful EVT as compared with a conventional BP target. Further research is required to identify the optimal BP management strategy after reperfusion.
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Affiliation(s)
- Xiao Dong
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Yuanyuan Liu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xuehong Chu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Erlan Yu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xiaole Jia
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chuanjie Wu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
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3
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Wang H, Guo Y, Xu J, Sun Y, Ji Y, Xu X, Yang Q, Huang X, Zhou Z. Blood pressure variability and outcome in atherosclerosis versus cardioembolism cerebral large vessel occlusion after successful thrombectomy. Hypertens Res 2024; 47:898-909. [PMID: 37978233 DOI: 10.1038/s41440-023-01500-x] [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: 03/02/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
Higher blood pressure variability (BPV) has been proven associated with worse functional outcome after endovascular treatment (EVT). However, this association is not established according to different stroke etiologies. In this study, we compared patients with the two highest proportions of stroke etiologies-cardioembolism (CE) and large-artery atherosclerosis (LAA), aiming to explore appropriate strategies of BP management for different etiologies. We enrolled patients with large vessel occlusion (LVO) in anterior circulation who underwent EVT and achieved successful recanalization retrospectively. 24-h blood pressure (BP) and BPV measured as blood pressure reduction (BPr), standard deviation (SD), coefficient of variation (CV), successive variation (SV), average real variability (ARV) after EVT were collected for systolic blood pressure (SBP) and diastolic blood pressure (DBP). The favorable outcome was defined as functional independence by 90-day modified Rankin Scale (mRS 0-2). In our cohort, higher BPV parameters significantly resulted in 90d functional dependence in CE-LVO patients (SBPSV OR: 1.083, 95%CI = 1.009-1.163; SBPARV OR: 1.121, 95%CI = 1.019-1.233; DBPSD OR: 1.124, 95%CI = 1.007-1.1256; DBPCV OR: 1.078, 95%CI = 1.002-1.161). However, for LAA-LVO patients, no positive results correlated 90d functional dependence with 24-hour BPV. Additionally, 90d functional dependence in CE patients with poor collaterals were significantly dependent on post-procedural BPV (DBPmax OR: 1.044, 95%CI = 1.002-1.087; DBPSD OR: 1.229, 95%CI = 1.022-1.1.479; DBPCV OR: 1.143, 95%CI = 1.009-1.295). Whereas to patients with good collaterals, there did not exist such a correlation. In summary, stroke etiologies should probably be taken into consideration to optimize individualized BP management strategies. In order to achieve better clinical outcomes for patients with acute ischemic stroke due to large vessel occlusion, stricter blood pressure management should be taken in cardioembolic stroke patients in contrast with large artery atherosclerotic stroke patients after successful endovascular therapy.
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Affiliation(s)
- Hao Wang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yapeng Guo
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Junfeng Xu
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yi Sun
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yachen Ji
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xiangjun Xu
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Qian Yang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xianjun Huang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China.
| | - Zhiming Zhou
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China.
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4
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Zhang K, Wang X, Wu Y, Liang F, Hou X, Zhang Z, Wang A, Liu L, Han R. Intensive Versus Standard Blood Pressure Management after Endovascular Therapy for Acute Ischemic Stroke: A Systematic Review and Meta-analysis. J Neurosurg Anesthesiol 2024:00008506-990000000-00100. [PMID: 38557945 DOI: 10.1097/ana.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/09/2024] [Indexed: 04/04/2024]
Abstract
Prospective clinical studies on blood pressure (BP) management targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) have recently been published. Our objective was to assess the impact on clinical outcomes of BP management guided by established systolic BP (SBP) targets within the first 24 hours after successful EVT. Four randomized controlled trials (RCTs) including 1556 participants across 5 SBP target settings identified from 5 databases up to September 6, 2023 were included in this systematic review and meta-analysis. All the intensive SBP target groups in these RCTs were combined to facilitate head-to-head comparisons. Patients receiving intensive SBP management had lower risk of 90-day functional independence as assessed by the modified Rankin scale score (relative risk [RR], 0.81; 95% confidence interval [CI], 0.72 to 0.91; I2, 12%), excellent outcomes (RR,0.86; 95% CI, 0.75 to 0.99; I2, 7%), favorable outcomes (RR, 0.85; 95% CI, 0.78 to 0.92; I2, 0%), and quality of life (standardized mean difference, -0.22; 95% CI, -0.35 to -0.10; I2,0%). There were no differences in the probability of any intracerebral hemorrhage (RR, 1.04; 95% CI, 0.92 to 1.19; I2,0%), symptomatic intracerebral hemorrhage (RR, 1.10; 95% CI, 0.76 to 1.60; I2, 0%), stroke-related death (RR, 1.16; 95% CI, 0.80 to 1.68; I2, 0%), or parenchymal hematoma (RR, 1.71; 95% CI, 0.74 to 3.98; I2, 47%) between SBP targets. This meta-analysis provides evidence from RCTs suggesting that intensive SBP control (target<160 mm Hg) may be detrimental to clinical outcomes in AIS patients with successful reperfusion after EVT.
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Affiliation(s)
- Kangda Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Xinyan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Youxuan Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Fa Liang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Xuan Hou
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Zihui Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Anxin Wang
- Department of Clinical Epidemiology and Clinical Trial, Beijing Tiantan Hospital, Capital Medical University
| | - Liping Liu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
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5
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Ghozy S, Mortezaei A, Elfil M, Abdelghaffar M, Kobeissi H, Aladawi M, Abbas AS, Nayak SS, Kadirvel R, Rabinstein AA, Kallmes DF. Intensive vs Conventional Blood Pressure Control After Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e240179. [PMID: 38386320 PMCID: PMC10884884 DOI: 10.1001/jamanetworkopen.2024.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/03/2024] [Indexed: 02/23/2024] Open
Abstract
Importance Endovascular thrombectomy (EVT) is standard treatment for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO), but optimal post-EVT blood pressure (BP) control remains debated. Objective To assess the association of different systolic BP targets following EVT with functional outcomes, mortality, and complications in patients with AIS due to LVO. Data Sources Systematic review and meta-analysis of databases (PubMed, Embase, Web of Science, Scopus, and Cochrane Library) to September 8, 2023. Study Selection Inclusion criteria consisted of randomized clinical trials examining post-EVT management of systolic BP in patients with AIS and LVO comparing intensive vs conventional targets. Nonrandomized studies, observational studies, noninterventional trials, meeting abstracts, duplicate studies, studies with overlapping data, and non-English language studies were excluded. Two authors independently applied these criteria through a blinded review, with discrepancies resolved through consensus. The risk of bias in the included studies was assessed using the revised tool for assessing risk of bias in randomized trials. Data Extraction and Synthesis This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Three authors extracted data regarding study characteristics, baseline patient data, and outcomes of interest. The pooled data were analyzed using a random-effects meta-analysis. Main Outcomes and Measures Rates of functional independence, 90-day mortality, symptomatic intracranial hemorrhage, and hypotensive events. Results A total of 4 randomized clinical trials with 1571 initially enrolled patients were included in the analysis. Lower functional independence rates were observed in the intensive control group (relative risk [RR], 0.81 [95% CI, 0.67-0.98]). No significant differences were found in 90-day mortality (RR, 1.18 [95% CI, 0.92-1.52]), symptomatic intracranial hemorrhage (RR, 1.12 [95% CI, 0.75-1.67]), or hypotensive events (RR, 1.80 [95% CI, 0.37-8.76]). There was minimal heterogeneity among the studies included in the functional independence outcome (I2 = 13% and τ2 = 0.003), which was absent among other outcomes (I2 = 0 and τ2 = 0). Conclusions and Relevance These findings suggest that intensive post-EVT BP reduction does not yield benefits and may carry risks. While awaiting the results of additional ongoing trials, a conservative BP management strategy after endovascular recanalization is favored in daily practice.
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Affiliation(s)
- Sherief Ghozy
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Ali Mortezaei
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha
| | | | | | - Mohammad Aladawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha
| | - Alzhraa S. Abbas
- Evidence-Based Practice Center, Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Sandeep S. Nayak
- Department of Internal Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
| | - Ramanathan Kadirvel
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
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6
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Xu H, Li H, Zhang P, Gao Y, Liu H, Shen H, Hua W, Zhang L, Li Z, Zhang Y, Xing P, Zhang X, Yang P, Liu J. Reperfusion status and postoperative blood pressure in acute stroke patients after endovascular treatment. Front Neurol 2023; 14:1238653. [PMID: 38020662 PMCID: PMC10668020 DOI: 10.3389/fneur.2023.1238653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Background and purpose An aggressive lowering of blood pressure (BP) could lead to neurological worsening, particularly of the area that has not been reperfused in acute stroke patients with large vessel occlusion (LVO). We sought to investigate the association of reperfusion status and BP course following mechanical thrombectomy (MT) with outcomes in LVO. Materials and methods Consecutive patients with LVO treated with MT between Jan 2020 to Jun 2021 were enrolled in a retrospective cohort study. Hourly systolic BP (SBP) and diastolic BP (DBP) were recorded for 72 h following MT and maximum SBP and DBP levels were identified. The Extended Thrombolysis in Cerebral Infarction (eTICI) scale was used to assess reperfusion extent. LVO patients were stratified in 2 groups based on reperfusion status: complete reperfusion (eTICI 3) and incomplete reperfusion (eTICI 2b/c). Three-month functional independence was defined as a modified Rankin Scale score of 0-2. Results A total of 263 acute ischemic stroke patients with LVO were retrospectively evaluated. Complete reperfusion was achieved in 210 patients (79.8%). Post-MT maximum SBP over 160 mmHg was significantly related to worse functional outcome (38.1% vs. 55.7%, p = 0.006), higher likelihood of in-hospital mortality and 3-month mortality (19.0% vs. 6.9%, p = 0.004, 27.4% vs. 14.3%, p = 0.012). No statistical correlation was found between reperfusion status and blood pressure level (p > 0.05). In patients with complete reperfusion, patients with an average BP 120-140 mmHg tends to have worse functional outcome compared with 100-120 mmHg (OR = 1.77, 95%CI: 0.97-3.23, p = 0.061). Conclusion High maximum SBP levels following MT are associated with an increased likelihood of 3-month functional dependence and mortality. An average BP of 100-120 mmHg tends to have better functional independence in completely reperfused patients. The effect of intensive BP control on incomplete reperfusion still warrants further investigations.
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Affiliation(s)
- Hongye Xu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- No. 904 Hospital of the PLA Joint Logistics Support Force, Wuxi, China
| | - He Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Department of Emergency, Naval Medical Center of PLA, Naval Medical University, Shanghai, China
| | - Ping Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yuan Gao
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Hanchen Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Hongjian Shen
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Weilong Hua
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongxin Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Xiaoxi Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
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Mistry EA, Hart KW, Davis LT, Gao Y, Prestigiacomo CJ, Mittal S, Mehta T, LaFever H, Harker P, Wilson-Perez HE, Beasley KA, Krothapalli N, Lippincott E, Stefek H, Froehler M, Chitale R, Fusco M, Grossman A, Shirani P, Smith M, Jaffa MN, Yeatts SD, Albers GW, Wanderer JP, Tolles J, Lindsell CJ, Lewis RJ, Bernard GR, Khatri P. Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial. JAMA 2023; 330:821-831. [PMID: 37668620 PMCID: PMC10481231 DOI: 10.1001/jama.2023.14330] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/11/2023] [Indexed: 09/06/2023]
Abstract
Importance The effects of moderate systolic blood pressure (SBP) lowering after successful recanalization with endovascular therapy for acute ischemic stroke are uncertain. Objective To determine the futility of lower SBP targets after endovascular therapy (<140 mm Hg or 160 mm Hg) compared with a higher target (≤180 mm Hg). Design, Setting, and Participants Randomized, open-label, blinded end point, phase 2, futility clinical trial that enrolled 120 patients with acute ischemic stroke who had undergone successful endovascular therapy at 3 US comprehensive stroke centers from January 2020 to March 2022 (final follow-up, June 2022). Intervention After undergoing endovascular therapy, participants were randomized to 1 of 3 SBP targets: 40 to less than 140 mm Hg, 40 to less than 160 mm Hg, and 40 to 180 mm Hg or less (guideline recommended) group, initiated within 60 minutes of recanalization and maintained for 24 hours. Main Outcomes and Measures Prespecified multiple primary outcomes for the primary futility analysis were follow-up infarct volume measured at 36 (±12) hours and utility-weighted modified Rankin Scale (mRS) score (range, 0 [worst] to 1 [best]) at 90 (±14) days. Linear regression models were used to test the harm-futility boundaries of a 10-mL increase (slope of 0.5) in the follow-up infarct volume or a 0.10 decrease (slope of -0.005) in the utility-weighted mRS score with each 20-mm Hg SBP target reduction after endovascular therapy (1-sided α = .05). Additional prespecified futility criterion was a less than 25% predicted probability of success for a future 2-group, superiority trial comparing SBP targets of the low- and mid-thresholds with the high-threshold (maximum sample size, 1500 with respect to the utility-weighted mRS score outcome). Results Among 120 patients randomized (mean [SD] age, 69.6 [14.5] years; 69 females [58%]), 113 (94.2%) completed the trial. The mean follow-up infarct volume was 32.4 mL (95% CI, 18.0 to 46.7 mL) for the less than 140-mm Hg group, 50.7 mL (95% CI, 33.7 to 67.7 mL), for the less than 160-mm Hg group, and 46.4 mL (95% CI, 24.5 to 68.2 mL) for the 180-mm Hg or less group. The mean utility-weighted mRS score was 0.51 (95% CI, 0.38 to 0.63) for the less than 140-mm Hg group, 0.47 (95% CI, 0.35 to 0.60) for the less than 160-mm Hg group, and 0.58 (95% CI, 0.46 to 0.71) for the high-target group. The slope of the follow-up infarct volume for each mm Hg decrease in the SBP target, adjusted for the baseline Alberta Stroke Program Early CT score, was -0.29 (95% CI, -0.81 to ∞; futility P = .99). The slope of the utility-weighted mRS score for each mm Hg decrease in the SBP target after endovascular therapy, adjusted for baseline utility-weighted mRS score, was -0.0019 (95% CI, -∞ to 0.0017; futility P = .93). Comparing the high-target SBP group with the lower-target groups, the predicted probability of success for a future trial was 25% for the less than 140-mm Hg group and 14% for the 160-mm Hg group. Conclusions and Relevance Among patients with acute ischemic stroke, lower SBP targets less than either 140 mm Hg or 160 mm Hg after successful endovascular therapy did not meet prespecified criteria for futility compared with an SBP target of 180 mm Hg or less. However, the findings suggested a low probability of benefit from lower SBP targets after endovascular therapy if tested in a future larger trial. Trial Registration ClinicalTrials.gov Identifier: NCT04116112.
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Affiliation(s)
- Eva A. Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Kimberly W. Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Larry T. Davis
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yue Gao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Shilpi Mittal
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tapan Mehta
- Ayer Neuroscience Institute, Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Hayden LaFever
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pablo Harker
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Kalli A. Beasley
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Neeharika Krothapalli
- Ayer Neuroscience Institute, Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Emily Lippincott
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Heather Stefek
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Froehler
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rohan Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aaron Grossman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Peyman Shirani
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Matthew Smith
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Matthew N. Jaffa
- Ayer Neuroscience Institute, Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Sharon D. Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | | | - Jonathan P. Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Juliana Tolles
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- Duke Clinical Research Institute, Durham, North Carolina
| | - Roger J. Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California
- Statistical Editor, JAMA
| | - Gordon R. Bernard
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
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8
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Anadani M, Maier B, Escalard S, Labreuche J, de Havenon A, Sabben C, Lapergue B, Mistry EA, Gory B, Spiotta AM, Richard S, Sibon I, Desilles JP, Blanc R, Piotin M, Mazighi M. Safety and efficacy of intensive systolic blood pressure lowering after successful endovascular therapy: a post hoc analysis of the BP TARGET trial. J Neurointerv Surg 2023; 15:e142-e147. [PMID: 36220337 DOI: 10.1136/jnis-2022-019130] [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: 05/07/2022] [Accepted: 08/28/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The Safety and Efficacy of Intensive Blood Pressure Lowering after Successful Endovascular Therapy in Acute Ischaemic Stroke (BP TARGET) trial demonstrated no benefit from intensive systolic blood pressure (SBP) treatment after successful reperfusion with endovascular therapy. However, it remains unknown if the response to blood pressure treatment is modified by other factors. OBJECTIVE To carry out a post hoc analysis of the BP TARGET trial data to determine if the response to blood pressure treatment is modified by factors such as age, history of hypertension, recanalization status, location of occlusion, diabetes, hyperglycemia, or pretreatment with intravenous thrombolysis. METHODS This is a post hoc analysis of the BP TARGET trial. Patients were divided into groups based on age, diabetes, blood glucose, site of occlusion, history of hypertension, and pretreatment with intravenous thrombolysis. The primary outcome was any intraparenchymal hemorrhage. RESULTS 318 patients were included. Diabetes modified the treatment effect on favorable functional outcome (Pheteogenity=0.041). There was a trend towards benefit from intensive SBP treatment in diabetic patients (OR=2.81; 95% CI 0.88 to 8.88; p=0.08) but not in non-diabetic patients (OR=0.75; 95% 0.45 to 126; p 0.28). Age, location of occlusion, admission SBP, pretreatment with intravenous thrombolysis, and history of hypertension did not modify the effect of intensive SBP treatment on any of the outcomes. CONCLUSION The effect of SBP lowering treatment was not modified by age, location of occlusion history of hypertension, intravenous thrombolysis, and admission SBP. Diabetes modified the effect of intensive SBP lowering treatment, and there was a trend towards benefit from intensive SBP treatment in diabetic patients. This finding is hypothesis generating and requires further validation.
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Affiliation(s)
- Mohammad Anadani
- Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Benjamin Maier
- Department of Interventional Neuroradiology, Adolphe de Rothschild Ophthalmological Foundation, Paris, France
| | - Simon Escalard
- Departement of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | | | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Candice Sabben
- Department of Neurology, Fondation Rothschild Hospital, paris, France
| | | | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | | | | | - Raphael Blanc
- Department of Interventional Neuroradiology, Fondation Rothschild, Paris, Île-de-France, France
| | - Michel Piotin
- Departement of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Mikaël Mazighi
- Departement of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
- Department of Neurology, GH Lariboisiere Fernand-Widal, Paris, France
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9
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Zhou Y, Chen Z, Fang J, Huang G. Blood pressure targets for acute ischemic stroke patients following endovascular thrombectomy: A meta-analysis. Clin Neurol Neurosurg 2023; 231:107835. [PMID: 37354634 DOI: 10.1016/j.clineuro.2023.107835] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE The objective of this meta-analysis was to explore the impact of different blood pressure levels following endovascular therapy on clinical outcomes, including safety and efficacy in acute ischemic stroke (AIS) patients. METHODS A systematic search was performed on PubMed, Embase, Cochrane Library, and Web of Science databases, covering studies published before February 1, 2023. Our primary outcomes were 90-day mRs 0-2 score, 90-day mortality, incidence of symptomatic intracranial hemorrhage(sICH), and hemicraniectomy. RESULTS The incidence of 90-day mRs= 2 score was no significant difference between different blood pressure values (OR=1.37, 95 % CI [0.82, 2.29], p = 0.23) with heterogeneity (I2 =85 %, p < 0.001). Subgroup analysis indicated that when the blood pressure targets were SBP< 140 mmHg (OR=1.73, 95 % CI [1.04, 2.90], p = 0.04) with heterogeneity (I2 =37 %, p = 0.20), and SBP< 130 mmHg (OR=1.58, 95 % CI [0.53, 4.70], p = 0.41) with heterogeneity (I2 =80 %, p = 0.02), there were statistic differences in the incidence of 90-day modified mRs 0-2 score. Regarding 90-day mortality, there was no significant difference between different blood pressure values (OR=0.75, 95 % CI [0.47, 1.21], p = 0.24; I2 =69 %, p = 0.007). As for the incidence of sICH, the difference was not statistically significant (OR = 0.82, 95 % CI [0.61, 1.09], p = 0.17; I2 =24 %, p = 0.26). However, subgroup analysis was performed due to different blood pressure values, and it was found that when the blood pressure targets were SBP<140 mmHg (OR=0.49, 95 % CI [0.28, 0.87], p = 0.02) and SBP<120 mmHg (OR = 0.84, 95 % CI [0.58, 1.23], p = 0.37), there were statistic differences in the incidence of sICH with SBP<140 mmHg. Furthermore, SBP<140 mmHg was associated with a lower incidence of hemicraniectomy (OR = 0.30, 95 % CI [0.15, 0.58], p<0.001). PROSPERO Register Number: CRD42022376706 CONCLUSION: The present meta-analysis findings indicate that intensive treatment is advantageous for achieving successful reperfusion in acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT). For different blood pressure targets (SBP < 140mmhg, SBP < 130mmhg, SBP < 120mmhg), with a reduction in systolic blood pressure (SBP) to less than 140 mmHg appearing to confer the greatest benefit. Furthermore, this study provides a significant blood pressure target that could inform the design of future multicentre, open-label, blinded-endpoint, randomized controlled trials.
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Affiliation(s)
- Yitao Zhou
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou City, Zhejiang Province, China
| | - Zixi Chen
- Department of Emergency Medcine, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou City, China
| | - Jinyan Fang
- Department of Emergency Medcine, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou City, China
| | - Ganying Huang
- Department of Emergency Medcine, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou City, China.
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10
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De Georgia M, Bowen T, Duncan KR, Chebl AB. Blood pressure management in ischemic stroke patients undergoing mechanical thrombectomy. Neurol Res Pract 2023; 5:12. [PMID: 36991520 PMCID: PMC10061853 DOI: 10.1186/s42466-023-00238-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
The relationship between presenting blood pressure in acute ischemic stroke patients and outcome is complex. Several studies have demonstrated a U-shaped curve with worse outcomes when blood pressure is high or low. The American Heart Association/American Stroke Association guidelines recommend values of blood pressure < 185/110 mmHg in patients treated with intravenous t-PA and "permissive hypertension" up to 220/120 mmHg in those not treated with intravenous t-PA. The optimal blood pressure target is less clear in patients undergoing mechanical thrombectomy. Before thrombectomy, the guidelines recommend a blood pressure < 185/110 mmHg though patients with even lower systolic blood pressures may have better outcomes. During and after thrombectomy, the guidelines recommend a blood pressure < 180/105 mmHg. However, several studies have suggested that during thrombectomy the primary goal should be to prevent significant low blood pressure (e.g., target systolic blood pressure > 140 mmHg or MAP > 70 mmHg). After thrombectomy, the primary goal should be to prevent high blood pressure (e.g., target systolic blood pressure < 160 mmHg or MAP < 90 mmHg). To make more specific recommendations, large, randomized-control studies are needed that address factors such as the baseline blood pressure, timing and degree of revascularization, status of collaterals, and estimated risk of reperfusion injury.
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Affiliation(s)
- Michael De Georgia
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Theodore Bowen
- Department of Neurology, MetroHealth Medical Center, Cleveland, OH, USA
| | - K Rose Duncan
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alex Bou Chebl
- Department of Neurology, Henry Ford Medical Center, Detroit, MI, USA
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11
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Luo T, Cui JS, Peng H, Xiang X, Xu Y, Yang H. Effect of blood pressure on the prognosis of acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization. Clin Neurol Neurosurg 2022; 224:107540. [PMID: 36509017 DOI: 10.1016/j.clineuro.2022.107540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/26/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE To explore the effect of blood pressure on the prognosis of acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization. METHODS Acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization were retrospectively collected. All patients were divided into the functional independent group and non-functional independent group, death group and non-death group based on the 90-day mRS score. Logistic regression was applied to analyze the relationship between the highest systolic blood pressure, the average systolic blood pressure, the lowest systolic blood pressure, the highest diastolic blood pressure, the average diastolic blood pressure, the lowest diastolic blood pressure in the first 24 h after admission and the functional prognosis as well as the complications after 90 days. The independent impact factors selected from regression analysis were used to investigate the blood pressure with prognostic value by receiver operating characteristic curve (ROC). RESULTS A total of 70 patients were recruited in this study. Among them, 39 cases (55.71%) were male and 31 cases (44.29%) were female, with a mean age of 61.83 ± 15.24 years old. 15 cases (21.43%) had a favorable 90-day outcome, and the other 55 cases (78.57%) had a higher mRS Score. After a 90-day follow-up, univariate analysis showed that hypertension and hyperlipidemia, highest systolic blood pressure, mean systolic blood pressure and NIHSS score were statistically significant in two groups with or without functional independence, while the NIHSS score at admission, systolic blood pressure at admission, average systolic blood pressure, highest systolic blood pressure and diastolic blood pressure were statistically significant in patients with death outcomes (P < 0.05). Multivariate regression analysis suggested that the highest systolic blood pressure was statistically significant (P < 0.05), the further ROC curve results showed the cut-off value of the highest systolic blood pressure was 180.5 mmHg, with a sensitivity of 82.35% and a specificity of 81.13%. The highest Youden's index was 0.6348. CONCLUSION For acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization, the appropriate reduction of blood pressure within 24 h after admission may have a positive effect on the clinical prognosis. The 90-day mortality of acute ischemic stroke patients without revascularization was independently related to the highest systolic blood pressure. The risk of death was increased when the highest systolic blood pressure was greater than 180.5 mmHg.
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Affiliation(s)
- Tao Luo
- Clinical Medical College of Guizhou Medical University, Guizhou, China
| | - Jun Shuan Cui
- Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Han Peng
- Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Xin Xiang
- Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Yuan Xu
- Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Hua Yang
- Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China..
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12
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Bath PM, Song L, Silva GS, Mistry E, Petersen N, Tsivgoulis G, Mazighi M, Bang OY, Sandset EC. Blood Pressure Management for Ischemic Stroke in the First 24 Hours. Stroke 2022; 53:1074-1084. [PMID: 35291822 DOI: 10.1161/strokeaha.121.036143] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High blood pressure (BP) is common after ischemic stroke and associated with a poor functional outcome and increased mortality. The conundrum then arises on whether to lower BP to improve outcome or whether this will worsen cerebral perfusion due to aberrant cerebral autoregulation. A number of large trials of BP lowering have failed to change outcome whether treatment was started prehospital in the community or hospital. Hence, nuances on how to manage high BP are likely, including whether different interventions are needed for different causes, the type and timing of the drug, how quickly BP is lowered, and the collateral effects of the drug, including on cerebral perfusion and platelets. Specific scenarios are also important, including when to lower BP before, during, and after intravenous thrombolysis and endovascular therapy/thrombectomy, when it may be necessary to raise BP, and when antihypertensive drugs taken before stroke should be restarted. This narrative review addresses these and other questions. Although further large trials are ongoing, it is increasingly likely that there is no simple answer. Different subgroups of patients may need to have their BP lowered (eg, before or after thrombolysis), left alone, or elevated.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (P.M.B.)
| | - Lili Song
- The George Institute China at Peking University Health Science Center, Beijing (L.S.)
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Sydney, Australia (L.S.)
| | - Gisele S Silva
- Neurology, Federal University of São Paulo (UNIFESP) and Hospital Israelita Albert Einstein, Brazil (G.S.S.)
| | - Eva Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (E.M.)
| | - Nils Petersen
- Department of Neurology, Divisions of Vascular Neurology and Neurocritical Care, Yale School of Medicine, New Haven (N.P.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (G.T.)
| | - Mikael Mazighi
- Department of Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris, INSERM 1148, FHU Neurovasc, France (M.M.)
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.)
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Norway (E.C.S.)
- The Norwegian Air Ambulance Foundation, Oslo (E.C.S.)
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13
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Anadani M, Maïer B, Escalard S, Labreuche J, de Havenon A, Sabben C, Lapergue B, Gory B, Richard S, Sibon I, Desilles JP, Blanc R, Piotin M, Mazighi M. Magnitude of Blood Pressure Change After Endovascular Therapy and Outcomes: Insight From the BP-TARGET Trial. Stroke 2022; 53:719-727. [PMID: 35109685 DOI: 10.1161/strokeaha.121.036701] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To assess the association between systolic blood pressure change (ΔSBP) at different time intervals after successful reperfusion with radiographic and clinical outcomes. METHODS This is a post hoc analysis of the BP-TARGET multicenter trial (Blood Pressure Target in Acute Stroke to Reduce Hemorrhage After Endovascular Therapy). ΔSBP was defined as end of procedure SBP minus mean SBP at different time intervals (15-60 minutes, 1-6 hours, and 6-24 hours postprocedure). The primary outcome was the poor functional outcome (90-day modified Rankin Scale score 3-6). RESULTS We included a total of 267 patients (130 in the intensive treatment group). Compared with patients with favorable outcome, patients with poor outcome had lower ΔSBP (less SBP reduction) at all times intervals. After adjusting for potential confounders including baseline SBP, both ΔSBP15-60M and ΔSBP6-24H were associated with lower odds of poor outcome (adjusted odds ratio per 5 mm Hg SBP reduction, 0.89 [95% CI, 0.81-0.99], and adjusted odds ratio 0.82 [95% CI, 0.73-0.92], respectively). Concerning safety outcomes, patients with intraparenchymal hemorrhage had lower ΔSBP at all time intervals. ΔSBP15-60M was associated with lower odds of any intraparenchymal hemorrhage (adjusted odds ratio per 5 mm Hg SBP reduction 0.91 [95% CI, 0.83-0.99]). Conversely, ΔSBP was not associated with mortality or neurological deterioration at any time interval. CONCLUSIONS After successful reperfusion, ΔSBP had a linear relationship with poor outcome and the risk of poor outcome was higher with less reduction from the baseline SBP. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03160677.
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Affiliation(s)
- Mohammad Anadani
- Department of Neurology, Washington University, St Louis, MO (M.A.).,Department of Neurosurgery, Medical University of South Carolina, Charleston (M.A.)
| | - Benjamin Maïer
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.).,University of Paris, France (B.M., J.-P.D., M.M.).,FHU Neurovasc, Paris, France (B.M., J.-P.D., R.B., M.P., M.M.)
| | - Simon Escalard
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.)
| | - Julien Labreuche
- University of Lille, CHU Lille, ULR 2694-METRICS: Évaluation des technologies de santé et des pratiques médicales, France (J.L.).,CHU Lille, Department of Biostatistics, France (J.L.)
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City (A.d.H.)
| | | | - Bertrand Lapergue
- Division of Neurology, Department of Neurology, Stroke Centre, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France (B.L.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Nancy, France (B.G.).,Université de Lorraine, IADI, INSERM U1254, Nancy, France (B.G.)
| | | | | | - Jean-Philippe Desilles
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.).,University of Paris, France (B.M., J.-P.D., M.M.).,FHU Neurovasc, Paris, France (B.M., J.-P.D., R.B., M.P., M.M.)
| | - Raphael Blanc
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.).,FHU Neurovasc, Paris, France (B.M., J.-P.D., R.B., M.P., M.M.)
| | - Michel Piotin
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.).,FHU Neurovasc, Paris, France (B.M., J.-P.D., R.B., M.P., M.M.)
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.).,University of Paris, France (B.M., J.-P.D., M.M.).,FHU Neurovasc, Paris, France (B.M., J.-P.D., R.B., M.P., M.M.)
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14
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Maïer B, Gory B, Lapergue B, Sibon I, Escalard S, Kyheng M, Labreuche J, de Havenon A, Petersen N, Anadani M, Gayat E, Boursin P, Ben Maacha M, Desilles JP, Blanc R, Piotin M, Halimi JM, Mazighi M. Effect of blood pressure variability in the randomized controlled BP TARGET trial. Eur J Neurol 2021; 29:771-781. [PMID: 34821437 DOI: 10.1111/ene.15194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE The Blood Pressure Target in Acute Ischemic Stroke to Reduce Hemorrhage After Endovascular Therapy (BP TARGET) trial evaluated whether an intensive systolic blood pressure (SBP) target resulted in reduced rates of intracranial hemorrhage (ICH) after successful endovascular therapy (EVT) but did not assess the effect of blood pressure variability (BPV) on functional outcomes and ICH occurrence. We sought to evaluate this question in the BP TARGET trial. METHODS We performed a post hoc analysis of the BP TARGET trial and included patients with at least 50% of blood pressure (BP) recordings during the first 24 h after EVT. BPV parameters were SBP and diastolic BP (DBP) coefficient of variation (CV), standard deviation (SD), maximum-minimum (max-min), successive variation (SV), and time rate. The primary outcome was favorable functional outcome (3-month modified Rankin Scale between 0 and 2); the secondary outcome was the rate of ICH at 24 h. RESULTS We included 290 patients (mean number of BP measures = 30.4, SD = 8.0). BPV parameters (SBPSD , SBPmax-min , SBPCV ) were higher in the intensive SBP target group. Only DBP BPV parameters were associated with worse functional outcomes in the unadjusted model (DBPSD , DBPmax-min , DBPCV , and DBPSV ), but not after adjustment. Higher SBPmax-min was associated with worse functional outcomes in Thrombolysis in Cerebral Infarction 2B patients (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.38-1.02), but not in patients with complete reperfusion (OR = 1.27, 95% CI = 0.80-2.02, p for heterogeneity (phet =0.037). None of the BPV parameters was associated with ICH, regardless of the randomization group or the reperfusion grade. CONCLUSIONS BPV was significantly higher in the intensive SBP target group but was not associated with functional outcome or ICH.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,University of Paris, Paris, France.,FHU NeuroVasc, Paris, France.,EA4245-Transplantation, Immunology, and Inflammation, University of Tours, Tours, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, University of Lorraine, Nancy, France.,IADI, INSERM U1254, University of Lorraine, Nancy, France
| | - Bertrand Lapergue
- Division of Neurology, Department of Neurology, Stroke Center, Foch Hospital, Versailles Saint-Quentin-en-Yvelines University, Suresnes, France
| | - Igor Sibon
- Stroke Unit, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Simon Escalard
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France
| | - Maeva Kyheng
- University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France
| | - Julien Labreuche
- University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France
| | - Adam de Havenon
- Neurology Department, University of Utah, Salt Lake City, Utah, USA
| | - Nils Petersen
- Neurocritical Care and Emergency Neurology, Yale School of Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Mohammad Anadani
- Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Etienne Gayat
- University of Paris, Paris, France.,Department of Anesthesiology, Critical Care and Burn Center, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, Paris, France.,INSERM UMR-S 942, Cardiovascular Makers in Stress Conditions, Paris, France
| | - Perrine Boursin
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France
| | - Malek Ben Maacha
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,University of Paris, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Raphael Blanc
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Jean-Michel Halimi
- EA4245-Transplantation, Immunology, and Inflammation, University of Tours, Tours, France.,Nephrology Department, Tours Hospital, Tours, France.,University of Tours, Tours, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,University of Paris, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
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15
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Krishnan R, Mays W, Elijovich L. Complications of Mechanical Thrombectomy in Acute Ischemic Stroke. Neurology 2021; 97:S115-S125. [PMID: 34785610 DOI: 10.1212/wnl.0000000000012803] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 06/23/2021] [Indexed: 01/01/2023] Open
Abstract
Multiple randomized clinical trials have supported the use of mechanical thrombectomy (MT) as standard of care in the treatment of large vessel occlusion acute ischemic stroke. Optimal outcomes depend not only on early reperfusion therapy but also on post thrombectomy care. Early recognition of post MT complications including reperfusion hemorrhage, cerebral edema and large space occupying infarcts, and access site complications can guide early initiation of lifesaving therapies that can improve neurologic outcomes. Knowledge of common complications and their management is essential for stroke neurologists and critical care providers to ensure optimal outcomes. We present a review of the available literature evaluating the common complications in patients undergoing MT with emphasis on early recognition and management.
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Affiliation(s)
- Rashi Krishnan
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - William Mays
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Lucas Elijovich
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis.
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16
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Kim BJ, Singh N, Menon BK. Hemodynamics of Leptomeningeal Collaterals after Large Vessel Occlusion and Blood Pressure Management with Endovascular Treatment. J Stroke 2021; 23:343-357. [PMID: 34649379 PMCID: PMC8521259 DOI: 10.5853/jos.2021.02446] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 12/14/2022] Open
Abstract
Endovascular therapy (EVT) is an effective treatment for ischemic stroke due to large vessel occlusion (LVO). Unlike intravenous thrombolysis, EVT enables visualization of the restoration of blood flow, also known as successful reperfusion in real time. However, until successful reperfusion is achieved, the survival of the ischemic brain is mainly dependent on blood flow from the leptomeningeal collaterals (LMC). It plays a critical role in maintaining tissue perfusion after LVO via pre-existing channels between the arborizing pial small arteries or arterioles overlying the cerebral hemispheres. In the ischemic territory where the physiologic cerebral autoregulation is impaired and the pial arteries are maximally dilated within their capacity, the direction and amount of LMC perfusion rely on the systemic perfusion, which can be estimated by measuring blood pressure (BP). After the EVT procedure, treatment focuses on mitigating the risk of hemorrhagic transformation, potentially via BP reduction. Thus, BP management may be a key component of acute care for patients with LVO stroke. However, the guidelines on BP management during and after EVT are limited, mostly due to the scarcity of high-level evidence on this issue. In this review, we aim to summarize the anatomical and physiological characteristics of LMC to maintain cerebral perfusion after acute LVO, along with a landscape summary of the literature on BP management in endovascular treatment. The objective of this review is to describe the mechanistic association between systemic BP and collateral perfusion after LVO and thus provide clinical and research perspectives on this topic.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Nishita Singh
- Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Bijoy K. Menon
- Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
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17
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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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18
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Abstract
Purpose of Review In this review article we will discuss the acute hypertensive response in the context of acute ischemic stroke and present the latest evidence-based concepts of the significance and management of the hemodynamic response in acute ischemic stroke. Recent Findings Acute hypertensive response is considered a common hemodynamic physiologic response in the early setting of an acute ischemic stroke. The significance of the acute hypertensive response is not entirely well understood. However, in certain types of acute ischemic strokes, the systemic elevation of the blood pressure helps to maintain the collateral blood flow in the penumbral ischemic tissue. The magnitude of the elevation of the systemic blood pressure that contributes to the maintenance of the collateral flow is not well established. The overcorrection of this physiologic hemodynamic response before an effective vessel recanalization takes place can carry a negative impact in the final clinical outcome. The significance of the persistence of the acute hypertensive response after an effective vessel recanalization is poorly understood, and it may negatively affect the final outcome due to reperfusion injury. Summary Acute hypertensive response is considered a common hemodynamic reaction of the cardiovascular system in the context of an acute ischemic stroke. The reaction is particularly common in acute brain embolic occlusion of large intracranial vessels. Its early management before, during, and immediately after arterial reperfusion has a repercussion in the final fate of the ischemic tissue and the clinical outcome.
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19
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Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke (BP-TARGET): a multicentre, open-label, randomised controlled trial. Lancet Neurol 2021; 20:265-274. [DOI: 10.1016/s1474-4422(20)30483-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 01/10/2023]
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20
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Anadani M, Matusevicius M, Tsivgoulis G, Peeters A, Nunes AP, Mancuso M, Roffe C, de Havenon A, Ahmed N. Magnitude of blood pressure change and clinical outcomes after thrombectomy in stroke caused by large artery occlusion. Eur J Neurol 2021; 28:1922-1930. [PMID: 33682232 DOI: 10.1111/ene.14807] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Extremes of both high and low systolic blood pressure (SBP) after mechanical thrombectomy (MT) in large artery occlusion stroke are known predictors of unfavorable outcome. However, the effect of SBP change (∆SBP) during the first 24 h on thrombectomy outcomes remains unclear. We aimed to investigate the association between ∆SBP at different time intervals and thrombectomy outcomes. METHODS We analyzed MT-treated patients registered in the SITS International Stroke Thrombectomy Registry from January 1, 2014 to September 3, 2019. Primary outcome was 3-month unfavorable outcome (modified Rankin scale scores 3-6). We defined ∆SBP as the mean SBP of a given time interval after MT (0-2, 2-4, 4-12, 12-24 h) minus admission SBP. Multivariable mixed logistic regression models were used to adjust for known confounders and center as random effect. Subgroup analyses were included to contrast specific subpopulations. Restricted cubic splines were used to model the associations. RESULTS The study population consisted of 5835 patients (mean age 70 years, 51% male, median NIHSS 16). Mean ∆SBP was -12.3, -15.7, -17.2, and -16.9 mmHg for the time intervals 0-2, 2-4, 4-12 h, and 12-24 h, respectively. Higher ∆SBP was associated with unfavorable outcome at 0-2 h (odds ratio 1.065, 95% confidence interval 1.014-1.118), 2-4 h (1.140, 1.081-1.203), 4-12 h (1.145, 1.087-1.203), and 12-24 h (1.145, 1.089-1.203), for every increase of 10 mmHg. Restricted cubic spline models suggested that increasing ∆SBP was associated with unfavorable outcome, with higher values showing increased risk of unfavorable outcome. CONCLUSION SBP increase after thrombectomy in large artery occlusion stroke is associated with poor functional outcome.
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Affiliation(s)
- Mohammad Anadani
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Marius Matusevicius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Ana Paiva Nunes
- Stroke Unit Centro Hospitalar Universitário de Lisboa Central - Hospital São José, Lisbon, Portugal
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Christine Roffe
- Stroke Research in Stoke, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurovascular Disease, Karolinska University Hospital, Stockholm, Sweden
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21
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Rodgers ML, Fox E, Abdelhak T, Franker LM, Johnson BJ, Kirchner-Sullivan C, Livesay SL, Marden FA. Care of the Patient With Acute Ischemic Stroke (Endovascular/Intensive Care Unit-Postinterventional Therapy): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association. Stroke 2021; 52:e198-e210. [PMID: 33691467 DOI: 10.1161/str.0000000000000358] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Ischemic stroke remains the fifth leading cause of death in the United States. Nurses play a pivotal role in the care of patients throughout the continuum. With the advances in stroke care, including mechanical thrombectomy, the American Heart Association/American Stroke Association charged the writing panel to complement the 2009 clinical practice guideline, "Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient," with current evidence-based nursing care. This update is 1 of a 3-part series focusing on emergency medical services/emergency care, endovascular/intensive care unit care, and postacute care. The aim of this scientific statement is to review and present current evidence, complications, best practices, and clinical practice strategies to provide current comprehensive scientific information for nursing care in the neuroendovascular area and intensive care unit in conjunction with medical treatments, including intravenous thrombolysis and mechanical thrombectomy.
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22
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An J, Tang Y, Cao X, Yuan H, Wei M, Yuan X, Zhang A, Li Y, Saguner A, Li G, Luo G. Systemic arterial blood pressure and intracerebral hemorrhage after mechanical thrombectomy in anterior cerebral circulation. J Investig Med 2021; 69:1008-1014. [PMID: 33653704 PMCID: PMC8223637 DOI: 10.1136/jim-2020-001554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 12/11/2022]
Abstract
The relationship between systemic arterial blood pressure (BP) and intracerebral hemorrhage (ICH) after mechanical thrombectomy (MT) of the cerebral artery remains unclear. This study aimed to determine the effect of BP variables on ICH after MT in patients with acute occlusions of the anterior cerebral circulation. Patients undergoing MT due to acute occlusions of the anterior cerebral circulation were enrolled in this single-center study. Non-invasive BP data following MT were obtained within the first 24 hours, including mean, maximum, minimum, difference between maximum and minimum, SD and coefficient of variation for systolic BP (SBP) and diastolic BP (DBP) and mean arterial pressure. ICH was defined and classified according to the European Cooperative Acute Stroke Study-II. In 164 enrolled patients (median age 65 (IQR 56–75) years; 31.7% female), higher maximum (89.5 mm Hg vs 98.5 mm Hg, p=0.001) and SD (9.8 mm Hg vs 10.9 mm Hg, p=0.038) of DBP were associated with higher risk of ICH. The optimal cut-off values associated with ICH for maximum SBP were 155 mm Hg and for maximum DBP 92.5 mm Hg, respectively. Higher BP within 24 hours after MT in acute occlusions of the anterior cerebral circulation is associated with a greater risk of ICH. More studies are needed to further determine optimal BP goals in the acute phase after MT.
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Affiliation(s)
- Jiaqi An
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yonglan Tang
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiangqi Cao
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Huijie Yuan
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Meng Wei
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xingyun Yuan
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Aifeng Zhang
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yongxin Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ardan Saguner
- Department of Cardiology, University Heart Center Zürich, Zürich, Switzerland
| | - Guoliang Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guogang Luo
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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23
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Liu D, Nie X, Pan Y, Yan H, Pu Y, Wei Y, Cai Y, Ding Y, Lu Q, Zhang Z, Gu W, Hou X, Yang Z, Wen M, Wang P, Ma G, Ma N, Miao Z, Leng X, Yan B, Davis SM, Wang Y, Liu L. Adverse Outcomes Associated With Higher Mean Blood Pressure and Greater Blood Pressure Variability Immediately After Successful Embolectomy in Those With Acute Ischemic Stroke, and the Influence of Pretreatment Collateral Circulation Status. J Am Heart Assoc 2021; 10:e019350. [PMID: 33634704 PMCID: PMC8174261 DOI: 10.1161/jaha.120.019350] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background To investigate whether collateral status could modify the associations between post‐thrombectomy blood pressure (BP) measures and outcomes. Methods and Results Patients with anterior‐circulation large‐vessel‐occlusion successfully recanalized in a multicenter endovascular thrombectomy registry were enrolled. Pretreatment collateral status was graded and dichotomized (good/poor) in angiography. Maximum, minimum, and mean systolic BP (SBP) and BP variability (assessed by the SD, coefficient of variation) during the initial 24 hours after endovascular thrombectomy were obtained. The primary outcome was unfavorable 90‐day outcome (modified Rankin Scale score 3–6). Secondary outcomes included symptomatic intracranial hemorrhage and 90‐day mortality. Adjusted odds ratios (aOR) of BP parameters over the outcomes were obtained in all patients and in patients with good/poor collaterals. Among 596 patients (mean age 66 years; 59.9% males), 302 (50.7%) patients had unfavorable 90‐day outcome. In multivariable analyses, higher mean SBP (aOR, 1.59 per 10 mm Hg increment; 95% CI, 1.26–2.02; P<0.001), mean SBP >140 mm Hg (versus ≤120 mm Hg; aOR, 4.27; 95% CI, 1.66–10.97; P=0.002), and higher SBP SD (aOR, 1.08 per 1‐SD increment; 95% CI, 1.01–1.16; P=0.02) were respectively associated with unfavorable 90‐day outcome in patients with poor collateral but not in those with good collateral. A marginal interaction between SBP coefficient of variation tertiles and collaterals on 90‐day functional outcome (P for interaction, 0.09) was observed. A significant interaction between SBP coefficient of variation tertiles and collaterals on 90‐day mortality (P for interaction, 0.03) was observed. Conclusions Higher postprocedural BP is associated with 90‐day unfavorable outcomes after successful endovascular thrombectomy in patients with poor collateral. Registration URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1900022154.
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Affiliation(s)
- Dacheng Liu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Ximing Nie
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuesong Pan
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Hongyi Yan
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuehua Pu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yufei Wei
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuan Cai
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yarong Ding
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Qixuan Lu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Zhe Zhang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Weibin Gu
- Department of Radiology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Xinyi Hou
- Department of Radiology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Zhonghua Yang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Miao Wen
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Penglian Wang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Gaoting Ma
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Ning Ma
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Zhongrong Miao
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Prince of Wales Hospital Chinese University of Hong Kong Hong Kong SAR China
| | - Bernard Yan
- Department of Medicine and Neurology Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of Melbourne Parkville Victoria Australia
| | - Stephen M Davis
- Department of Medicine and Neurology Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of Melbourne Parkville Victoria Australia
| | - Yongjun Wang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Liping Liu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
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24
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Optimal blood pressure levels in different phases of peripheral thrombolysis period in acute ischemic stroke. J Hypertens 2021; 39:1453-1461. [PMID: 33560058 DOI: 10.1097/hjh.0000000000002812] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dramatic changes of blood pressure (BP) were observed in the peripheral thrombolysis period, however, there is no consensus about BP control targets in the different phases. METHODS We retrospectively studied a consecutive sample of 510 patients treated with intravenous thrombolysis and followed-up for 3 months. The peripheral thrombolysis period was divided into these phases: Phase 1 (from onset to thrombolysis), Phase 2 (thrombolysis), Phase 3 (from thrombolysis to 24 h after thrombolysis), and Phase 4 (from 24 h to 7 days after thrombolysis). Patients were divided into quintiles according to mean blood pressure in these phases, respectively. Neurological improvement was evaluated using the modified Rankin Scale score at 3-month after thrombolysis. RESULTS Lower risk of intracerebral hemorrhage within 7 days was found in lower quintiles of SBP (OR = 0.100, 95% CI 0.011-0.887, P = 0.039 in Phase 1 quintile Q1, OR = 0.110, 95% CI 0.012-0.974, P = 0.047 in Phase 2-3 quintile Q1, and OR, 0.175, 95% CI, 0.035-0.872; P = 0.033 in Phase 4 quintile Q2, respectively). Better neurological improvement was found in SBP quintiles: Q2-Q4 (127.3-155.7 mmHg) in Phase 4 (OR = 3.095, 95% CI 1.524-6.286, P = 0.002 for Q2; OR = 2.697, 95% CI 1.354-5.370, P = 0.005 for Q3; and OR = 2.491, 95% CI 1.263-4.913, P = 0.008 for Q4, respectively). Our results also showed higher average real variability of SBP was negatively associated with better neurological outcome in Phase 1 and Phase 2-3. CONCLUSIONS Maintaining SBP levels (≤148 mmHg) from admission to the first 24 h after thrombolysis, then keeping SBP levels (127-138 mmHg) would be beneficial.
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25
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Wu K, Xiong Z, Ding Y. Management of Elevated Blood Pressure After Stroke Thrombectomy for Anterior Circulation. Risk Manag Healthc Policy 2021; 14:405-413. [PMID: 33568958 PMCID: PMC7868952 DOI: 10.2147/rmhp.s285316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/25/2021] [Indexed: 12/11/2022] Open
Abstract
Thrombectomy is superior to intravenous thrombolysis for patients with large vessel occlusion in acute ischemic stroke, but nearly half of the patients still experience poor functional outcomes. Elevated blood pressure (BP) is widely observed in acute ischemic stroke, and BP may be one of the modifiable parameters that can potentially influence the outcomes; however, only observational studies exist to support current guidelines, and the recommended range for BP after thrombectomy is too wide to meet the clinical requirement. Randomized controlled trials are therefore needed to better understand the relationship between BP and outcomes after thrombectomy. In this review, we introduce the current management of BP after thrombectomy and several aspects of postthrombectomy BP management that should be resolved in future clinical trials.
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Affiliation(s)
- Kexin Wu
- Postgraduate School, Dalian Medical University, Dalian, People's Republic of China.,Department of Neurosurgery, Taizhou People's Hospital, Taizhou, People's Republic of China
| | - Zhencheng Xiong
- Institute of Medical Technology, Peking University Health Science Center, Beijing, People's Republic of China.,Peking University Third Hospital, Beijing, People's Republic of China
| | - Yasuo Ding
- Postgraduate School, Dalian Medical University, Dalian, People's Republic of China.,Department of Neurosurgery, Taizhou People's Hospital, Taizhou, People's Republic of China
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26
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Maïer B, Delvoye F, Labreuche J, Escalard S, Desilles JP, Redjem H, Hébert S, Smajda S, Ciccio G, Lapergue B, Blanc R, Piotin M, Mazighi M. Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review. Front Neurol 2020; 11:573382. [PMID: 33193021 PMCID: PMC7659685 DOI: 10.3389/fneur.2020.573382] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: Optimal blood pressure (BP) targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) still need to be assessed, especially according to the recanalization status. Facing the lack of randomized controlled trials addressing this question, we performed a systematic review of studies assessing the post-EVT BP impact on functional outcome and symptomatic intracranial hemorrhage (sICH). Methods: Studies published after January 1, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work. Results: Five studies were included in the present analysis. Despite a significant heterogeneity among studies which precluded a meta-analysis, systolic BP (SBP) was the most frequently used parameter to describe BP. BP variability (standard deviation, successive variability) after EVT was associated with worse functional outcome, especially in studies without specific BP targets after successful EVT. Lower BP values after successful EVT were associated with lower odds of sICH. Four studies evaluated the post-EVT BP impact on recanalized patients solely, with only one specifically addressing the impact of a TICI 2B vs. 2C. Interestingly, SBP reduction was inversely associated with worse outcomes in TICI 3 patients but not in TICI 2B patients, pointing to the potential value of BP management according to the exact TICI. Conclusions: BP post-EVT seems to be associated with worse functional outcomes and sICH. However, given the important heterogeneity depicted among the included studies, no decisive conclusion can be made from this systematic review, thus underlying the urgent need of randomized controlled trials evaluating this question.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
- Université de Paris, Paris, France
| | - François Delvoye
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Julien Labreuche
- University Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Simon Escalard
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Hocine Redjem
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Solène Hébert
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Stanislas Smajda
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Gabriele Ciccio
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | | | - Raphaël Blanc
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
- FHU Neurovasc, Paris, France
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Anadani M, de Havenon A, Yaghi S, Mehta T, Arora N, Starosciak AK, De Los Rios La Rosa F, Siegler J, Mistry AM, Chitale R, Spiotta AM, Tsivgoulis G, Khatri P, Mistry EA. Blood pressure reduction and outcome after endovascular therapy: a secondary analysis of the BEST study. J Neurointerv Surg 2020; 13:698-702. [PMID: 32883780 DOI: 10.1136/neurintsurg-2020-016494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/28/2020] [Accepted: 08/01/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Elevated systolic blood pressure (SBP) in the acute phase after endovascular therapy (EVT) is associated with worse outcome. However, the association between systolic blood pressure reduction (SBPr) and the outcome of EVT is not well understood. OBJECTIVE To determine the association between SBPr and clinical outcomes after EVT in a prospective multicenter cohort. METHODS A post hoc analysis of the Blood Pressure after Endovascular Stroke Therapy (BEST) prospective observational cohort study was carried out. SBPr was defined as the absolute difference between admission SBP and mean SBP in the first 24 hours after EVT. Logistic regression was used to assess the association between SBPr and poor functional outcome (modified Rankin Scale score 3-6) at 90 days. RESULTS A total of 259/433 (58.5%) patients had poor outcome. SBPr was higher in the poor outcome group than in the good outcome group (26.6±27.4 vs 19.0±22.3 mm Hg; p<0.001). However, in adjusted models, SBPr was not independently associated with poor outcome (OR=1.00 per 1 mm Hg increase, 95% CI 0.99 to 1.01) or death (OR=0.9 per 1 mm Hg increase; 95% CI 0.98 to 1.00). No association remained when SBPr was divided into tertiles. Subgroup analyses based on history of hypertension, revascularization status, and antihypertensive treatment yielded similar results. CONCLUSION The reduction in baseline SBP following EVT was not associated with poor functional outcomes. Most of the cohort (88%) achieved successful recanalization, and therefore, these results mainly apply to patients with successful recanalization.
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Affiliation(s)
- Mohammad Anadani
- Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.,Department of Neurology, Medical University of South Carolina - College of Medicine, Charleston, South Carolina, USA
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, Brooklyn, New York, USA
| | - Tapan Mehta
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Niraj Arora
- Department of Neurology, University of Missouri, Columbia, South Carolina, USA
| | - Amy Kathryn Starosciak
- Neuroscience Center - 2 Clarke, Baptist Hospital, Miami, Florida, USA.,Center for Research, Baptist Health South Florida, Coral Gables, Florida, USA
| | | | - James Siegler
- Department of Neurology, Cooper University Health, Camden, New Jersey, USA
| | - Akshitkumar M Mistry
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rohan Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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28
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Anadani M, Arthur AS, Tsivgoulis G, Simpson KN, Alawieh A, Orabi Y, Goyal N, Alexandrov AV, Maier IL, Psychogios M, Liman J, Brinton D, Swisher CB, Shah S, Inamullah O, Keyrouz S, Kansagra AP, Allen M, Giles JA, Wolfe SQ, Fargen KM, Gory B, De Marini P, Kan P, Nascimento FA, Almallouhi E, Petersen N, Kodali S, Rahman S, Richard S, Spiotta AM. Blood Pressure Goals and Clinical Outcomes after Successful Endovascular Therapy: A Multicenter Study. Ann Neurol 2020; 87:830-839. [DOI: 10.1002/ana.25716] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Mohammad Anadani
- Department of NeurosurgeryMedical University of South Carolina Charleston SC USA
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Adam S. Arthur
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Georgios Tsivgoulis
- Department of NeurosurgeryUniversity of Tennessee Health Science Center Memphis TN USA
| | - Kit N. Simpson
- Department of NeurologyAttikon University Hospital, School of Medicine, National and Kapodistrian University of Athens Athens Greece
| | - Ali Alawieh
- Department of NeurosurgeryMedical University of South Carolina Charleston SC USA
| | - Yser Orabi
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Nitin Goyal
- Department of NeurologyUniversity Medical Center Göttingen Göttingen Germany
| | - Andrei V. Alexandrov
- Department of NeurologyUniversity of Tennessee Health Science Center Memphis TN USA
| | - Ilko L. Maier
- Department of NeurologyUniversity Medical Center Göttingen Göttingen Germany
| | | | - Jan Liman
- Department of NeurologyUniversity Medical Center Göttingen Göttingen Germany
| | - Daniel Brinton
- Department of Healthcare Leadership and ManagementMedical University of South Carolina Charleston SC USA
| | | | - Shreyash Shah
- Department of NeurologyDuke University Hospital Durham NC USA
| | - Ovais Inamullah
- Department of NeurologyDuke University Hospital Durham NC USA
| | - Salah Keyrouz
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - Akash P. Kansagra
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - Michelle Allen
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - James A. Giles
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - Stacey Q. Wolfe
- Department of NeurosurgeryWake Forest University Winston‐Salem NC USA
| | - Kyle M. Fargen
- Department of NeurosurgeryWake Forest University Winston‐Salem NC USA
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic NeuroradiologyUniversity Hospital of Nancy Nancy France
| | - Pierre De Marini
- Department of Diagnostic and Therapeutic NeuroradiologyUniversity Hospital of Nancy Nancy France
| | - Peter Kan
- Department of NeurosurgeryBaylor College of Medicine Houston TX USA
| | | | - Eyad Almallouhi
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Nils Petersen
- Department of NeurologyYale New Haven Hospital New Haven CT USA
| | - Sreeja Kodali
- Department of NeurologyYale New Haven Hospital New Haven CT USA
| | - Shareena Rahman
- Department of NeurologyDuke University Hospital Durham NC USA
| | - Sébastien Richard
- Department of NeurologyStroke Unit, University Hospital of Nancy Nancy France
| | - Alejandro M. Spiotta
- Department of NeurosurgeryMedical University of South Carolina Charleston SC USA
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