Does the admission blood pressure associate with short- and long term outcome in stroke patients treated with thrombolysis? A single centre study

Outcome predictors in anterior and posterior ischemic strokes: a study based on the Iranian SITS registry

Ischemic stroke is the major form of stroke with two separate vascular territories. Many risk factors are related to stroke outcomes in both territories. The present descriptive research was carried out on the basis of data obtained from the Safe Implementation of Treatments in Stroke (SITS) registry on Iranian intravenous thrombolysis ischemic stroke cases. Vascular territory involved in each case and three-month excellent outcome, functional independence, mortality rate, and brain hemorrhage occurrence were determined. Univariable and multivariable logistics regression analyses were utilized in order to investigate association of ischemic stroke outcomes with the vascular territory involved and other related factors. Among 1566 patients 95.4% was anterior circulation stroke patients and 4.6% was posterior circulation stroke cases. There is no significant association between vascular territory with mortality (OR of PCS vs ACS: 0.74, 95% CI 0.37-1.46), excellent functional outcome (OR 0.72, 95% CI 0.44-1.19), functional outcome (OR 0.86, 95% CI 0.52-1.42) and local hemorrhage (OR 0.98, 95% CI 0.30-3.21). Among major risk factors, age, diabetes, NIHSS score and admission duration, increased significantly odds of three-month mortality, excellent outcome, and functional independence in the multivariate analysis. The highest of odds was in NIHSS score with a dose-response association. The vascular territory was not an outcome predictor in ischemic strokes. The most important predictor was baseline NIHSS.

Transport Blood Pressures and Outcomes in Stroke Patients Requiring Thrombectomy

OBJECTIVE

Mechanical thrombectomy is the treatment of choice for acute ischemic strokes from large vessel occlusions. Absolute blood pressure and blood pressure variability (BPV) may affect patients' outcome. We hypothesized that patients' outcomes were not associated with BPV during transport between hospitals in the era of effective thrombectomy.

METHODS

We performed a retrospective observational review of adult patients admitted to our comprehensive stroke center who underwent mechanical thrombectomy between January 1, 2015, and December 31, 2018. Data were collected from our stroke registry and transportation records. Outcomes were defined as 90-day modified Rankin Scale (mRS) ≤2 and any acute kidney injury (AKI) during hospitalization.

RESULTS

We analyzed 134 eligible patients. The mean age was 66 years (standard deviation = 14 years). Forty percent achieved mRS ≤2, and 16% had an AKI. BPV and maximum systolic blood pressures during transport were examined as variables to determine outcome. We found BPV was similar between patients with good and bad functional independence. Furthermore, the maximum systolic blood pressure during transport (odds ratio = 0.98; 95% confidence interval, 0.96-0.99; P = .038), not BPV, was associated with a lower likelihood of mRS ≤2. No similar correlation of analyzed blood pressure variables could be found for AKI as an outcome.

CONCLUSION

The maximum systolic blood pressure was associated with worse functional outcomes in stroke patients transported for thrombectomy. Prehospital clinicians should be cognizant of high blood pressure among patients with acute ischemic stroke from large vessel occlusion during transport and treat accordingly.

The Relationship Between Admission Systolic Blood Pressure and Mortality in Telestroke Patients

Background: A "U-shaped" relationship between admission blood pressure (BP) and mortality (wherein patients within a middle range have better outcomes than patients at higher or lower extremes) in patients receiving intravenous recombinant tissue-plasminogen activator (tPA) has been previously described. We aim to determine if this U-shaped relationship persists for patients in a telestroke setting regardless of tPA administration. Materials and Methods: We conducted a retrospective chart review of the prospectively collected registry data for all patients seen through the Medical University of South Carolina (MUSC) telestroke network. Admission systolic BP (SBP) was divided into quartiles with thresholds based on the 25th, 50th, and 75th percentiles as cut points separately by tPA status. The primary outcomes of this study were odds of 90-day modified Rankin scale ≤2 and 90-day mortality. Logistic regression analyses were used to analyze associations between BP quartiles and these outcomes, adjusted for relevant clinical covariates. Results: Our sample comprised 1,232 patients evaluated for telestroke, 616 of whom received tPA. Patients in the second (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.77 in the tPA group, OR 0.27, 95% CI 01.0-0.78 in the non-tPA group) and third (OR 0.26, 95% CI 0.11-0.64 in the tPA group, OR 0.36, 95% CI 0.14-0.92 in the non-tPA group) quartiles of admission SBP had lower adjusted odds of 90-day mortality. Conclusions: Our findings support a U-shaped relationship between admission SBP and 90-day mortality in acute stroke patients regardless of tPA administration, after adjustment for relevant covariates. Further research into interventions regarding BP management poststroke is warranted.

Blood pressure control for acute severe ischemic and hemorrhagic stroke

PURPOSE OF REVIEW

Severe ischemic or hemorrhagic stroke is a devastating cerebrovascular disease often demanding critical care. Optimal management of blood pressure (BP) in the acute phase is controversial. The purpose of this review is to display insights from recent studies on BP control in both conditions.

RECENT FINDINGS

BP control in acute ischemic stroke has recently been investigated with regard to endovascular recanalizing therapies. Decreases from baseline BP and hypotension during the intervention have been found detrimental. Overall, a periinterventional SBP between 140 and 160 mmHg appeared favorable in several studies. In acute hemorrhagic stroke, the recently completed Antihypertensive Treatment of Acute Cerebral Hemorrhage II trial confirmed feasibility of early aggressive BP reduction but failed to demonstrate a reduction in hematoma growth or a clinical benefit.

SUMMARY

Recent findings do not support benefits of intensive BP lowering in both acute hemorrhagic and ischemic stroke, with the possible exception of the postinterventional phase after successful endovascular recanalization of large-vessel occlusions. Although optimal ranges of BP values remain to be defined, high BP should still be treated according to guidelines. As stroke patients requiring critical care are underrepresented in most studies on BP, caution in transferring these findings is warranted and prospective research in that patient population needed.

Systolic Blood Pressure Within 24 Hours After Thrombectomy for Acute Ischemic Stroke Correlates With Outcome

Background

Current guidelines suggest treating blood pressure above 180/105 mm Hg during the first 24 hours in patients with acute ischemic stroke undergoing any form of recanalization therapy. Currently, no studies exist to guide blood pressure management in patients with stroke treated specifically with mechanical thrombectomy. We aimed to determine the association between blood pressure parameters within the first 24 hours after mechanical thrombectomy and patient outcomes.

Methods and Results

We retrospectively studied a consecutive sample of adult patients who underwent mechanical thrombectomy for acute ischemic stroke of the anterior cerebral circulation at 3 institutions from March 2015 to October 2016. We collected the values of maximum, minimum, and average values of systolic blood pressure, diastolic blood pressure, and mean arterial pressures in the first 24 hours after mechanical thrombectomy. Primary and secondary outcomes were patients’ functional status at 90 days measured on the modified Rankin scale and the incidence and severity of intracranial hemorrhages within 48 hours. Associations were explored using an ordered multivariable logistic regression analyses. A total of 228 patients were included (mean age 65.8±14.3; 104 males, 45.6%). Maximum systolic blood pressure independently correlated with a worse 90‐day modified Rankin scale and hemorrhagic complications within 48 hours (adjusted odds ratio=1.02 [1.01–1.03], P=0.004; 1.02 [1.01–1.04], P=0.002; respectively) in multivariable analyses, after adjusting for several possible confounders.

Conclusions

Higher peak values of systolic blood pressure independently correlated with worse 90‐day modified Rankin scale and a higher rate of hemorrhagic complications. Further prospective studies are warranted to identify whether systolic blood pressure is a therapeutic target to improve outcomes.

Blood Pressure in Acute Ischemic Stroke

Hypertension is present in up to 84% of patients presenting with acute stroke, and a smaller proportion of patients have blood pressures that are below typical values in the context of cerebral ischemia. Outcomes are generally worse in those who present with either low or severely elevated blood pressure. Several studies have provided valuable information about malignant trends in blood pressure during the transition from the acute to the subacute phase of stroke. It is not uncommon for practitioners in clinical practice to identify what appear to be pressure-dependent neurologic deficits. Despite physiologic and clinical data suggesting the importance of blood pressure modulation to support cerebral blood flow to ischemic tissue, randomized controlled trials have not yielded robust evidence for this in acute ischemic stroke. We highlight previous studies involving acute-stroke patients that have defined trends in blood pressure and that have evaluated the safety and efficacy of blood-pressure modulation in acute ischemic stroke. This overview reports the current status of this topic from the perspective of a stroke neurologist and provides a framework for future research.