1
|
Xu H, Sun D, Song L, Mo D, Ma N, Wang A, Gao F, Zhang X, Jia B, Miao Z. Association of baseline blood pressure and outcomes in etiology subtypes of large vessel occlusion stroke: Data from ANGEL-ACT registry. J Neuroradiol 2024; 51:101213. [PMID: 39127370 DOI: 10.1016/j.neurad.2024.101213] [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: 05/12/2024] [Revised: 08/02/2024] [Accepted: 08/03/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Blood pressure (BP) management at the initial stage of stroke caused by large-vessel occlusion (LVO) remains challenging. We assessed the association between baseline BP and clinical and safety outcomes of endovascular treatment (EVT) in different stroke etiologies. METHODS Patients with acute ischemic stroke and anterior circulation LVO were screened from a prospective, multicenter registry of EVT from November 2017 to March 2019. The primary outcome was poor 90-day outcome (modified Rankin Scale score 3-6). The safety outcome was 24 h post-procedure parenchymal hematoma (PH). The Trial of Org 101072 in Acute Stroke Treatment criteria were used for etiologic stroke classification. Restricted cubic spline and binary logistic regression analysis were performed to examine the association between study outcomes and natural log-transformed BP. RESULTS In subgroup analyses, a U-shaped correlation existed between baseline mean arterial pressure (MAP) and poor outcome in large-artery atherosclerosis stroke only. Higher MAP was an independent risk factor compared with a central reference value (≥ 133 mm Hg vs 96-115 mm Hg; adjusted OR [aOR], 2.50; 95 % CI, 1.09 to 5.71, P = 0.030). Whereas elevated MAP was associated with PH (aOR, 1.58; 95 % CI 1.04 to 2.39, P = 0.030 for a ln10-unit increase in natural log-transformed MAP) in the range <110 mm Hg exclusively for cardioembolic stroke. CONCLUSION Whether it is cause or epiphenomenon, baseline BP was associated with 90-day outcome in large-artery atherosclerosis stroke, whereas in cardioembolic stroke baseline BP was correlated with post-procedure PH within a certain range. Identifying these features based on etiological subtypes may offer a reference for BP management in acute LVO stroke.
Collapse
Affiliation(s)
- Haifeng Xu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ligang Song
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuelei Zhang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Franx B, Dijkhuizen RM, Dippel DWJ. Acute Ischemic Stroke in the Clinic and the Laboratory: Targets for Translational Research. Neuroscience 2024; 550:114-124. [PMID: 38670254 DOI: 10.1016/j.neuroscience.2024.04.006] [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: 01/03/2024] [Revised: 03/26/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
Ischemic stroke research has enabled significant advancements in diagnosis, treatment, and management of this debilitating disease, yet challenges remain standing in the way of better patient prognoses. In this narrative review, a fictional case illustrates challenges and uncertainties that medical professionals still face - penumbra identification, lack of neuroprotective agents, side-effects of tissue plasminogen activator, dearth of molecular biomarkers, incomplete microvascular reperfusion or no-reflow, post-recanalization hyperperfusion, blood pressure management and procedural anesthetic effects. The current state of the field is broadly reviewed per topic, with the aim to introduce a broad audience (scientist and clinician alike) to recent successes in translational stroke research and pending scientific queries that are tractable for preclinical assessment. Opportunities for co-operation between clinical and experimental stroke experts are highlighted to increase the size and frequency of strides the field makes to improve our understanding of this disease and ways of treating it.
Collapse
Affiliation(s)
- Bart Franx
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Rick M Dijkhuizen
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Diederik W J Dippel
- Stroke Center, Dept of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands.
| |
Collapse
|
4
|
Wang Q, Yin J, Xu L, Lu J, Chen J, Chen Y, Wufuer A, Gong T. Development and validation of outcome prediction model for reperfusion therapy in acute ischemic stroke using nomogram and machine learning. Neurol Sci 2024; 45:3255-3266. [PMID: 38277052 DOI: 10.1007/s10072-024-07329-7] [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: 10/11/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024]
Abstract
OBJECTIVE To develop logistic regression nomogram and machine learning (ML)-based models to predict 3-month unfavorable functional outcome for acute ischemic stroke (AIS) patients undergoing reperfusion therapy. METHODS Patients undergoing reperfusion therapy (intravenous thrombolysis and/or endovascular treatment) were prospectively recruited. Unfavorable outcome was defined as 3-month modified Rankin Scale (mRS) score 3-6. The independent risk factors associated with unfavorable outcome were obtained by regression analysis and included in the prediction model. The performance of nomogram was assessed by the area under the curve (AUC), calibration curve, and decision curve analysis (DCA). ML models were compared with nomogram using AUC; the generalizability of all models was ascertained in an external cohort. RESULTS A total of 505 patients were enrolled, with 256 in the model construction, and 249 in the external validation. Five variables were identified as prognostic factors: baseline NIHSS, D-dimer level, random blood glucose (RBG), blood urea nitrogen (BUN), and systolic blood pressure (SBP) before reperfusion. The AUC values of nomogram were 0.865, 0.818, and 0.779 in the training set, test set, and external validation, respectively. The calibration curve and DCA indicated appreciable reliability and good net benefits. The best three ML models were extra trees (ET), CatBoost, and random forest (RF) models; all of them showed favorable discrimination in the training cohort, and confirmed in the test and external sets. CONCLUSION Baseline NIHSS, D-dimer, RBG, BUN, and SBP before reperfusion were independent predictors for 3-month unfavorable outcome after reperfusion therapy in AIS patients. Both nomogram and ML models showed good discrimination and generalizability.
Collapse
Affiliation(s)
- Qianwen Wang
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100084, People's Republic of China
| | - Jiawen Yin
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China
| | - Lei Xu
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China
| | - Jun Lu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China
| | - Juan Chen
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China
| | - Yuhui Chen
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China.
| | - Alimu Wufuer
- Department of Neurology, the First Affiliated Hospital of Xinjiang Medical University, No. 137 South Liyushan Road, Urumqi, 830054, Xinjiang, People's Republic of China.
| | - Tao Gong
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China.
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100084, People's Republic of China.
| |
Collapse
|
5
|
Medicherla C, Pashun R, Al-Mufti F. Review of Cerebral Collateral Circulation and Insight into Cardiovascular Strategies to Limit Collateral Damage in Ischemic Stroke. Cardiol Rev 2024; 32:188-193. [PMID: 37729598 DOI: 10.1097/crd.0000000000000614] [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] [Indexed: 09/22/2023]
Abstract
Cerebral collateral circulation is a dynamic and adaptive process by which alternative vascular pathways supply perfusion to ischemic brain tissue in the event of an arterial occlusion. This complicated network of blood vessels that acts as a natural bypass plays a pivotal role in stroke pathophysiology and has become a key area of study given its significance in stroke treatment and patient outcomes. In this review, we will study the factors influencing the formation, recruitment, and endurance of collateral vessels; discuss imaging modalities for quantitative and qualitative assessment of this network; explore the role of collaterals in stroke management; and highlight several cardiovascular strategies to minimize damage to collaterals and optimize stroke outcomes.
Collapse
Affiliation(s)
| | - Raymond Pashun
- Department of Cardiology, New York University Langone Health, New York, NY
| | - Fawaz Al-Mufti
- Department of Neurology, Neurosurgery, and Radiology, New York Medical College, Valhalla, NY
| |
Collapse
|
6
|
Cai L, Ding Y, Rajah G, Tong Y, Duan H, Han Z, Gao J, Cheng Z, Xin R, Jiang S, Geng X. Rapid Intravenous Glyceryl Trinitrate in Ischemic Damage (RIGID): A potential neuroprotection strategy for acute ischemic stroke (AIS) patients. Neurotherapeutics 2024; 21:e00365. [PMID: 38658264 DOI: 10.1016/j.neurot.2024.e00365] [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: 11/20/2023] [Revised: 03/28/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
Despite advances in intravenous thrombolysis and endovascular thrombectomy, numerous acute ischemic stroke survivors continue to experience various disability levels. The nitric oxide (NO) donor, Glyceryl Trinitrate (GTN), has been identified as a potential neuroprotective agent against ischemic damage. We evaluated the safety and feasibility of intravenous GTN in AIS patients. Subsequently, we conducted a secondary analysis to assess for possible efficacy of GTN as a neuroprotectant. We conducted a prospective, double-blind, randomized controlled trial in the Stroke Intervention & Translational Center (SITC) in Beijing Luhe Hospital, Capital Medical University (ChiCTR2100046271). AIS patients within 24 h of stroke onset were evenly divided into GTN or control groups (n = 20 each). The GTN group received intravenous GTN (5 mg in 50 ml saline at a rate of 0.4 mg/h for 12.5 h/day over 2 days), while controls were administered an equivalent volume of 0.9% saline. Both groups followed standard Stroke Guidelines for treatment. Safety measures focused on SBP<110 mmHg and headache occurrence. Efficacy was assessed via the 90-day modified rankin score (mRS) and the national institutes of health stroke score (NIHSS). Of the 40 AIS patients, baseline characteristics such as age, gender, risk factors, and pre-mRS scores showed no significant difference between the groups. Safety measures of SBP<110 mmHg and headache occurrence were comparable. Overall, 90-day mRS (1 vs. 1) and NIHSS (1 vs. 1) did not significantly differ between groups. However, the GTN-treated group had a benefit in enhancing NIHSS recovery (△NIHSS 4.5 vs. 3, p = 0.028), indicating that GTN may augment recovery. Subgroup analyses revealed a benefit in the GTN group at the 90-day NIHSS score and △NIHSS follow up for non-thrombolysis patients (1 vs. 2, p = 0.016; 5 vs. 2, p = 0.001). Moreover, the GTN group may benefit mild stroke patients in NIHSS score at 90 day and △NIHSS observed at 90 days (1 vs. 1, p = 0.025; 3 vs. 2 p = 0.002). Overall, while preliminary data suggest GTN might aid recovery in NIHSS improvement, the evidence is tempered due to sample size limitations. The RIGID study confirms the safety and feasibility of intravenous GTN administration for AIS patients. Preliminary data also suggest that the GTN group may provide improvement in NIHSS recovery compared to the control group. Furthermore, a potential benefit for non-thrombolysis patients and those with mild stroke symptoms was identified, suggesting a possible potential role as a tailored intervention in specific AIS subgroups. Due to the limited sample size, further larger RCT will be necessary to replicate these results. TRIAL REGISTRATION: www.chictr.org.cn, identifier: ChiCTR2100046271.
Collapse
Affiliation(s)
- Lipeng Cai
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA.
| | - Gary Rajah
- Department of Neurosurgery, Munson Medical Center, Traverse City, Mi, USA
| | - Yanna Tong
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Honglian Duan
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zhenzhen Han
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jie Gao
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zhe Cheng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Ruiqiang Xin
- Department of Medical Imaging, Luhe Hospital, Capital Medical University, Beijing, China
| | - Shangqian Jiang
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA; China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
7
|
Li B, Niu T, Dai Y, Bu L, Pan K, Lu L, Bo L. Intraoperative intensive blood pressure management strategy and the outcome of patients who had an acute ischaemic stroke undergoing endovascular treatment under general anaesthesia: study protocol for a prospective randomised controlled trial. BMJ Open 2024; 14:e079197. [PMID: 38569682 PMCID: PMC11146376 DOI: 10.1136/bmjopen-2023-079197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 03/01/2024] [Indexed: 04/05/2024] Open
Abstract
BackgroundEndovascular thrombectomy is the recommended treatment for acute ischaemic stroke, but the optimal blood pressure management strategy during the procedure under general anaesthesia remains controversial. In this study protocol, we propose an intraoperative intensive blood pressure range (110-140 mm Hg systolic blood pressure) based on a retrospective analysis and extensive literature review. By comparing the outcomes of patients who had an acute ischaemic stroke undergoing mechanical thrombectomy under general anaesthesia with standard blood pressure management (140-180 mm Hg systolic blood pressure) versus intensive blood pressure management, we aim to determine the impact of intraoperative intensive blood pressure management strategy on patient prognosis. METHODS AND ANALYSIS The study is a double-blinded, randomised, controlled study, with patients randomised into either the standard blood pressure management group or the intensive blood pressure management group. The primary endpoint of the study will be the sequential analysis of modified Rankin Scale scores at 90 days after mechanical thrombectomy. ETHICS AND DISSEMINATION The study has been approved by the ethics committee of Shanghai Changhai Hospital with an approval number CHEC2023-015. The results of the study will be published in peer-reviewed international journals. TRIAL REGISTRATION NUMBER ChiCTR2300070764.
Collapse
Affiliation(s)
- Binben Li
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ting Niu
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yuanqiang Dai
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lan Bu
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ke Pan
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lingyu Lu
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lulong Bo
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| |
Collapse
|
8
|
Robbe MMQ, Pinckaers FME, Olthuis SGH, Bos MJ, van Oostenbrugge RJ, van Zwam WH, Staals J, Postma AA. Procedural Blood Pressure and Intracranial Hemorrhage on Dual-Energy Computed Tomography After Endovascular Stroke Treatment. Cardiovasc Intervent Radiol 2024; 47:483-491. [PMID: 38062172 DOI: 10.1007/s00270-023-03619-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/06/2023] [Indexed: 04/07/2024]
Abstract
PURPOSE Optimal systolic blood pressure (SBP) management during endovascular treatment (EVT) for acute ischemic stroke remains a topic of debate. Though BP is associated with worse functional outcome, the relationship between BP and post-procedural intracranial hemorrhage (ICH) is less well-known. We aimed to investigate the association between BP during EVT and post-procedural ICH on dual-energy CT (DECT). METHODS We included all patients who underwent EVT for an anterior circulation large vessel occlusion between 2010 and 2019, and received DECT < 3 h post-EVT. All BP measurements during the EVT procedure were used to calculate mean arterial pressure (MAPmean), mean SBP (SBPmean), and SBPmax-min (highest minus lowest). ICH was assessed using virtual post-procedural unenhanced DECT reconstructions and classified as intraparenchymal or extraparenchymal. Symptomatic ICH was scored according to the Heidelberg criteria. The association between different BP parameters and ICH was assessed using multivariable logistic regression. RESULTS We included 478 patients. Seventy-six patients (16%) demonstrated ICH on DECT, of which 26 (34%) were intraparenchymal. Symptomatic intraparenchymal and extraparenchymal ICH occurred in 10 (38%) and 4 (8%) patients. SBPmax, SBPmean, and MAPmean were associated with intraparenchymal ICH with an adjusted odds ratio of 1.19 (95%CI, 1.02-1.39), 1.22 (95%CI, 1.03-1.46), and 1.40 (95%CI, 1.09-1.81) per 10 mmHg, while BP was not significantly associated with extraparenchymal ICH. BP did not differ between asymptomatic and symptomatic ICH. CONCLUSION Procedural BP is associated with intraparenchymal ICH on post-EVT DECT but not with extraparenchymal ICH. Future studies should evaluate whether individual procedural BP management reduces post-EVT ICH and improves clinical outcome.
Collapse
Affiliation(s)
- M M Q Robbe
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands.
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - F M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - S G H Olthuis
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M J Bos
- Departments of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - W H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J Staals
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands
- School for Mental Health and Sciences (MHENS), Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
9
|
Zompola C, Palaiodimou L, Voumvourakis K, Stefanis L, Katsanos AH, Sandset EC, Boviatsis E, Tsivgoulis G. Blood Pressure Variability in Acute Stroke: A Narrative Review. J Clin Med 2024; 13:1981. [PMID: 38610746 PMCID: PMC11012361 DOI: 10.3390/jcm13071981] [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: 03/12/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
The management of blood pressure variability (BPV) in acute stroke presents a complex challenge with profound implications for patient outcomes. This narrative review examines the role of BPV across various stages of acute stroke care, highlighting its impact on treatment strategies and prognostic considerations. In the prehospital setting, while guidelines lack specific recommendations for BP management, emerging evidence suggests a potential link between BPV and outcomes. Among ischaemic stroke patients who are ineligible for reperfusion therapies, BPV independently influences functional outcomes, emphasising the need for individualised approaches to BP control. During intravenous thrombolysis and endovascular therapy, the intricate interplay between BP levels, recanalisation status, and BPV is evident. Striking a balance between aggressive BP lowering and avoiding hypoperfusion-related complications is essential. Intracerebral haemorrhage management is further complicated by BPV, which emerges as a predictor of mortality and disability, necessitating nuanced BP management strategies. Finally, among patients with acute subarachnoid haemorrhage, increased BPV may be correlated with a rebleeding risk and worse outcomes, emphasizing the need for BPV monitoring in this population. Integration of BPV assessment into clinical practice and research protocols is crucial for refining treatment strategies that are tailored to individual patient needs. Future studies should explore novel interventions targeting BPV modulation to optimise stroke care outcomes.
Collapse
Affiliation(s)
- Christina Zompola
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Leonidas Stefanis
- First Department of Neurology, “Aeginition” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON L8L2X2, Canada
| | - Else C. Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, N-0424 Oslo, Norway
| | - Estathios Boviatsis
- Second Department of Neurosurgery, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| |
Collapse
|
10
|
Qiao X, Zheng F, Wei M, Zhao Z. The ratio of the maximum density values: a new method for predicting hemorrhagic transformation in acute ischemic stroke patients undergoing mechanical thrombectomy. Front Neurol 2024; 15:1357689. [PMID: 38585350 PMCID: PMC10996850 DOI: 10.3389/fneur.2024.1357689] [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: 12/18/2023] [Accepted: 03/13/2024] [Indexed: 04/09/2024] Open
Abstract
Background It is challenging yet critical to differentiate between hemorrhagic transformation (HT) and contrast extravasation on non-contrast-enhanced computed tomography (NCCT) scans following mechanical thrombectomy (MT) in patients with acute ischemic stroke. We propose a new method called the ratio of maximum density values (RMDV) to minimize the confusion of contrast extravasation and to evaluate the diagnostic significance of RMDV in predicting HT on immediate post-interventional NCCT scans. Methods We conducted a retrospective analysis of the prospective patients' database who received MT for acute ischemic stroke caused by occlusion of the intracranial large artery and showed postinterventional cerebral hyperdensities (PCHDs) on NCCT scans immediately after MT. Based on the subsequent NCCT scans, we divided patients with PCHDs into the HT and the non-HT groups. The clinical characters and radiological details were collected and compared to the two groups. We assessed the ability of RMDV >1 to predict HT by analyzing the receiver operating characteristic curve. Results One hundred and three patients showed PCHDs; 58 (56.31%) were classified as HT, while 45 (43.69%) were classified as non-HT. The only notable distinction between the two groups was the proportion of RMDV >1 in the HT group. The correlation between HT and RMDV >1 with an area under the curve of 0.826 (95% confidence interval, 0.739 to 0.894). The sensitivity, specificity, positive, and negative predictive values of RMDV >1 on NCCT for predicting HT were 89.66, 75.56, 82.54, and 85.00%, respectively. Conclusion The utilization of RMDV >1 on immediate NCCT scans after MT can predict early HT with good sensitivity and specificity.
Collapse
Affiliation(s)
- Xiaohong Qiao
- Department of Neurology, Weihai Central Hospital Affiliated to Qingdao University, Weihai, China
| | - Fuhao Zheng
- Department of Neurointervention, Weihai Central Hospital Affiliated to Qingdao University, Weihai, China
| | - Manman Wei
- Department of Neurology, Weihai Central Hospital Affiliated to Qingdao University, Weihai, China
| | - Zhenming Zhao
- Department of Neurointervention, Weihai Central Hospital Affiliated to Qingdao University, Weihai, China
| |
Collapse
|
11
|
Dammavalam V, Lin S, Nessa S, Daksla N, Stefanowski K, Costa A, Bergese S. Neuroprotection during Thrombectomy for Acute Ischemic Stroke: A Review of Future Therapies. Int J Mol Sci 2024; 25:891. [PMID: 38255965 PMCID: PMC10815099 DOI: 10.3390/ijms25020891] [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: 11/30/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Stroke is a major cause of death and disability worldwide. Endovascular thrombectomy has been impactful in decreasing mortality. However, many clinical results continue to show suboptimal functional outcomes despite high recanalization rates. This gap in recanalization and symptomatic improvement suggests a need for adjunctive therapies in post-thrombectomy care. With greater insight into ischemia-reperfusion injury, recent preclinical testing of neuroprotective agents has shifted towards preventing oxidative stress through upregulation of antioxidants and downstream effectors, with positive results. Advances in multiple neuroprotective therapies, including uric acid, activated protein C, nerinetide, otaplimastat, imatinib, verapamil, butylphthalide, edaravone, nelonemdaz, ApTOLL, regional hypothermia, remote ischemic conditioning, normobaric oxygen, and especially nuclear factor erythroid 2-related factor 2, have promising evidence for improving stroke care. Sedation and blood pressure management in endovascular thrombectomy also play crucial roles in improved stroke outcomes. A hand-in-hand approach with both endovascular therapy and neuroprotection may be the key to targeting disability due to stroke.
Collapse
Affiliation(s)
- Vikalpa Dammavalam
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Sandra Lin
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Sayedatun Nessa
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Neil Daksla
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Kamil Stefanowski
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Ana Costa
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| |
Collapse
|
12
|
Xu Q, Chen Y, Zheng X, Jiang Y, Xu C, Gao Q, Shi F, Zhang J. Clinical efficacy and safety of endovascular treatment for patients with wake-up stroke with large vessel occlusion guided by NCCT-ASPECTS. Interv Neuroradiol 2023:15910199231217145. [PMID: 38055995 DOI: 10.1177/15910199231217145] [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: 12/08/2023] Open
Abstract
OBJECTIVE To evaluate the clinical efficacy and safety of 6 to 24 h endovascular therapy (EVT) in patients with wake-up stroke (WUS) with acute large vessel occlusion (LVO) of the anterior circulation guided by noncontrast computed tomography-Alberta stroke program early CT score (NCCT-ASPECTS). METHODS Fifty-three patients with WUS with acute LVO of the anterior circulation who were treated at the Sir Run Run Shaw Hospital of Zhejiang Medical College from January 2018 to March 2021 were retrospectively analyzed. The patients were divided into NCCT-ASPECTS or CT perfusion groups. Baseline data, perioperative data, and 90-d prognostic information were compared between the two groups. Multivariable logistic regression analysis was used to determine the independent factors influencing outcomes. RESULTS There were no significant differences in the good prognosis, symptomatic intracranial hemorrhage, and mortality rates between the two groups (P > 0.05). Multivariate logistic regression analysis showed that the puncture-recanalization time was an independent factor for good prognosis. CONCLUSION Based on NCCT-ASPECTS guidance, EVT in patients with WUS for acute LVO of the anterior circulation within 6 to 24 h may be safe and effective.
Collapse
Affiliation(s)
- Qinglin Xu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yigang Chen
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xu Zheng
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Jiang
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chuan Xu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qingqing Gao
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Feina Shi
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinhua Zhang
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
13
|
Chen M, Meis J, Potreck A, Sauer LD, Kieser M, Bendszus M, Wick W, Ringleb PA, Möhlenbruch MA, Schönenberger S. Effect of Individualized Versus Standardized Blood Pressure Management During Endovascular Stroke Treatment on Clinical Outcome: A Randomized Clinical Trial. Stroke 2023; 54:2755-2765. [PMID: 37732489 DOI: 10.1161/strokeaha.123.044062] [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: 05/30/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Optimal blood pressure (BP) management during endovascular stroke treatment is not well established. We studied whether an individualized approach for managing BP during endovascular stroke treatment gives a better clinical outcome than an approach with standardized systolic BP targets. METHODS The INDIVIDUATE study (Individualized Blood Pressure Management During Endovascular Treatment of Acute Ischemic Stroke Under Procedural Sedation) is a randomized clinical trial with a prospective randomized open blinded end point (PROBE) design. Patients were recruited between October 1, 2020 and July 7, 2022 at a single center at a tertiary care university hospital. Patients were eligible, when they were suffering from acute ischemic stroke of the anterior circulation with occlusions of the internal carotid artery and middle cerebral artery and a National Institutes of Health Stroke Scale score of ≥8 receiving endovascular stroke treatment in procedural sedation. The intervention consists of an individualized BP management strategy, where preinterventional baseline systolic BP (SBP) values are used as intraprocedural BP targets. As a control, the standard treatment aims to maintain the intraprocedural SBP between 140 and 180 mm Hg. The main prespecified outcome is the proportion of favorable functional outcomes 90 days after stroke, defined as a modified Rankin Scale score of 0 to 2. RESULTS Two hundred fifty patients were enrolled and included in the analysis, mean (SD) age was 77 (12) years, 142 (57%) patients were women, and mean (SD) National Institutes of Health Stroke Scale score on admission was 17 (5.2). In all, 123 (49%) patients were treated with individualized and 127 (51%) with standard BP management. Mean (SD) intraprocedural SBP was similar in the individualized versus standard BP management group (157 [19] versus 154 [18] mm Hg; P=0.16). The rate of favorable functional outcome after 3 months was not significantly different between the individualized versus the standard BP management group (25% versus 24%; adjusted odds ratio, 0.81 [95% CI, 0.41-1.61]; P=0.56). CONCLUSIONS Among patients treated with endovascular stroke treatment due to an acute ischemic stroke of the anterior circulation, no significant difference was seen between the individualized BP management strategy, where intraprocedural SBP was targeted to baseline values, and the standardized regimen of targeting SBP between 140 and 180 mm Hg. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04578288.
Collapse
Affiliation(s)
- Min Chen
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Arne Potreck
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Lukas D Sauer
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Meinhard Kieser
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Martin Bendszus
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Wolfgang Wick
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Peter A Ringleb
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Silvia Schönenberger
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| |
Collapse
|
14
|
van den Berg SA, Uniken Venema SM, LeCouffe NE, Postma AA, Lycklama à Nijeholt GJ, Rinkel LA, Treurniet KM, Kappelhof M, Bruggeman AE, van Kranendonk KR, Majoie CBLM, Dippel DWJ, van der Worp HB, Coutinho JM, Nederkoorn PJ, Roos YBWEM. Admission blood pressure and clinical outcomes in patients with acute ischaemic stroke treated with intravenous alteplase and endovascular treatment versus endovascular treatment alone: A MR CLEAN-NO IV substudy. Eur Stroke J 2023; 8:647-654. [PMID: 37641554 PMCID: PMC10472956 DOI: 10.1177/23969873231173274] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/04/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION High systolic blood pressure (SBP) is associated with poor functional outcome. We analysed whether the association of SBP with outcomes after endovascular treatment (EVT) is modified by prior intravenous thrombolysis (IVT). PATIENTS AND METHODS This was a post-hoc analysis of MR CLEAN-NO IV, a randomised trial of IVT with alteplase followed by EVT versus EVT alone, within 4.5 h from stroke onset. SBP was recorded on hospital admission. The primary outcome was 90-day modified Rankin Scale (mRS) score and secondary outcomes included symptomatic intracranial haemorrhage (sICH) and successful reperfusion (eTICI 2b-3), analysed with (ordinal) logistic regression. Estimates were calculated per 10 mmHg change in SBP. We assessed whether IVT modified the associations of SBP with these outcomes using multiplicative interaction terms. RESULTS Of 539 randomised patients, 266 received IVT. The association of SBP with mRS score was J-shaped, with an inflection point at 150 mmHg. Using 150 mmHg as a reference point, SBPs higher than 150 mmHg were associated with poor functional outcome (acOR: 1.23, 95% CI: 1.09-1.38), but lower SBPs were not (acOR: 1.14, 95% CI: 0.99-1.30). Higher SBP was not associated with the risk of sICH (aOR: 1.09, 95% CI: 0.93-1.27) nor with the probability of successful reperfusion (aOR: 1.00, 95% CI: 0.91-1.10). Our main result was that we found no effect modification by IVT (p-values for interaction, mRS = 0.94; sICH = 0.26; successful reperfusion = 0.58). DISCUSSION AND CONCLUSION There was no effect modification of IVT with SBP for any of the clinical outcomes. Therefore, the level of SBP (if ⩽185/110 mmHg) should not guide IVT decisions in patients otherwise eligible for both IVT and EVT within the 4.5-h time window. TRIAL REGISTRATION ISRCTN80619088, https://www.isrctn.com/ISRCTN80619088.
Collapse
Affiliation(s)
- Sophie A van den Berg
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Natalie E LeCouffe
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- School for Mental Health and Sciences, Maastricht University, Maastricht, The Netherlands
| | | | - Leon A Rinkel
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Kilian M Treurniet
- Department of Radiology, Haaglanden Medical Center, Den Haag, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Agnetha E Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Katinka R van Kranendonk
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC – University Medical Center, Rotterdam, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
15
|
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.
Collapse
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.
| |
Collapse
|
16
|
Ahn S, Mummareddy N, Roth SG, Jo J, Bhamidipati A, Ko Y, DiNitto J, Chitale RV, Fusco MR, Froehler MT. The clinical utility of dual-energy CT in post-thrombectomy care: Part 1, predictors and outcomes of subarachnoid and intraparenchymal hemorrhage. J Stroke Cerebrovasc Dis 2023; 32:107217. [PMID: 37392485 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107217] [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: 05/01/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 07/03/2023] Open
Abstract
OBJECTIVES Dual-energy CT allows differentiation between blood and iodinated contrast. We aimed to determine predictors of subarachnoid and intraparenchymal hemorrhage on dual-energy CT performed immediately post-thrombectomy and the impact of these hemorrhages on 90-day outcomes. MATERIALS AND METHODS A retrospective analysis was performed on patients who underwent thrombectomy for anterior circulation large-vessel occlusion and subsequent dual-energy CT at a comprehensive stroke center from 2018-2021. The presence of contrast, subarachnoid hemorrhage, or intraparenchymal hemorrhage immediately post-thrombectomy was assessed by dual-energy CT. Univariable and multivariable analyses were performed to identify predictors of post-thrombectomy hemorrhages and 90-day outcomes. Patients with unknown 90-day mRS were excluded. RESULTS Of 196 patients, subarachnoid hemorrhage was seen in 17, and intraparenchymal hemorrhage in 23 on dual-energy CT performed immediately post-thrombectomy. On multivariable analysis, subarachnoid hemorrhage was predicted by stent retriever use in the M2 segment of MCA (OR,4.64;p=0.017;95%CI,1.49-14.35) and the number of thrombectomy passes (OR,1.79;p=0.019;95%CI,1.09-2.94;per an additional pass), while intraparenchymal hemorrhage was predicted by preprocedural non-contrast CT-based ASPECTS (OR,8.66;p=0.049;95%CI,0.92-81.55;per 1 score decrease) and preprocedural systolic blood pressure (OR,5.10;p=0.037;95%CI,1.04-24.93;per 10 mmHg increase). After adjusting for potential confounders, intraparenchymal hemorrhage was associated with worse functional outcomes (OR,0.25;p=0.021;95%CI,0.07-0.82) and mortality (OR,4.30;p=0.023,95%CI,1.20-15.36), while subarachnoid hemorrhage was associated with neither. CONCLUSIONS Intraparenchymal hemorrhage immediately post-thrombectomy was associated with worse functional outcomes and mortality and can be predicted by low ASPECTS and elevated preprocedural systolic blood pressure. Future studies focusing on management strategies for patients presenting with low ASPECTS or elevated blood pressure to prevent post-thrombectomy intraparenchymal hemorrhage are warranted.
Collapse
Affiliation(s)
- Seoiyoung Ahn
- Vanderbilt University School of Medicine, Nashville, TN.
| | - Nishit Mummareddy
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN.
| | - Steven G Roth
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN.
| | - Jacob Jo
- Vanderbilt University School of Medicine, Nashville, TN.
| | | | - Yeji Ko
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN.
| | - Julie DiNitto
- Siemens Medical Solutions, Malvern, PA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN.
| | - Rohan V Chitale
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN.
| | - Matthew R Fusco
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN.
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN.
| |
Collapse
|
17
|
Hoffman H, Cote JR, Wood J, Jalal MS, Otite FO, Masoud HE, Gould GC. The influence of pre-reperfusion blood pressure on outcomes following mechanical thrombectomy for anterior circulation large vessel occlusion. J Clin Neurosci 2023; 113:99-107. [PMID: 37247459 DOI: 10.1016/j.jocn.2023.05.016] [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: 03/23/2023] [Revised: 05/10/2023] [Accepted: 05/23/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND We evaluated how systolic blood pressure (SBP) and mean arterial pressure (MAP) parameters between presentation and reperfusion influence functional status and intracranial hemorrhage (ICH). METHODS All patients who underwent MT for LVO at a single institution were reviewed. Independent variables included SBP and MAP measurements obtained on presentation, between presentation and reperfusion (pre-reperfusion), and between groin puncture and reperfusion (thrombectomy). Mean, minimum, maximum, and standard deviations (SD) for SBP and MAP were calculated. Outcomes included 90-day favorable functional status, radiographic ICH (rICH), and symptomatic ICH (sICH). RESULTS 305 patients were included. Higher pre-reperfusion SBPmax was associated with rICH (OR 1.41, 95% CI 1.08-1.85) and sICH (OR 1.84, 95% CI 1.26-2.72). Higher SBPSD was also associated with rICH (OR 1.38, 95% CI 1.06-1.81) and sICH (OR 1.59, 95% CI 1.12-2.26). Greater SBPmax (OR 0.64, 95% CI 0.47-0.86), MAPmax (OR 0.72, 95% CI 0.52-0.97), SBPSD (OR 0.63, 95% CI 0.46-0.86), and MAPSD (0.63, 95% CI 0.45-0.84) during thrombectomy were associated with lower odds of 90-day favorable functional status. In a subgroup analysis, these associations were primarily limited to patients with intact collateral circulation. Optimal SBPmax cutoffs for predicting rICH were 171 (pre-reperfusion) and 179 mmHg (thrombectomy). Cutoffs for predicting sICH were 178 (pre-reperfusion) and 174 mmHg (thrombectomy). CONCLUSION Greater maximum BP and variability in BP during the pre-reperfusion period are associated with unfavorable functional status and ICH after MT for anterior circulation LVO.
Collapse
Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA.
| | - John R Cote
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Jacob Wood
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Muhammad S Jalal
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Fadar O Otite
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Hesham E Masoud
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Grahame C Gould
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
| |
Collapse
|
18
|
Hu M, Zhu Y, Chen Z, Li W, Li L, Li Y, Xia Y, Zhang T, Feng Q, Wu J, Wu M. Relationship between mean blood pressure during hospitalization and clinical outcome after acute ischemic stroke. BMC Neurol 2023; 23:156. [PMID: 37081452 PMCID: PMC10116692 DOI: 10.1186/s12883-023-03209-3] [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: 01/01/2023] [Accepted: 04/14/2023] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVE The optimal blood pressure (BP) targets for acute ischemic stroke are unclear. We aimed to assess the relationship between Mean BP and clinical outcomes during hospitalization. MATERIALS AND METHODS We included 649 patients with Acute ischemic stroke (AIS) from December 2020 to July 2021. BP was measured daily, and mean blood pressure was calculated. Clinical events recorded within 90 days of randomization were: recurrent ischemic stroke, symptomatic intracranial hemorrhage, and death. The modified Rankin Scale (mRS) was used to measure primary outcomes 3 months after AIS. Logistic multiple regression analysis was performed by statistical software R. RESULT There is a nonlinear U-shaped relationship between SBP and poor outcomes. This means higher SBP and lower SBP will increase the incidence of poor outcomes. The optimal mean SBP during hospitalization was 135-150 mmHg, and patients with SBP < 135mmhg OR 2.4 [95% Cl, (1.16 ~ 4.97)], P = 0.018; and > 150mmhg OR 2.04 [95% Cl, 1.02 ~ 4.08], p = 0.045 had a higher probability of poor outcomes. CONCLUSION Our study shows that the optimal SBP of patients with AIS during hospitalization was 135-150 mmHg. The findings suggest that the relationship between mean SBP and 3-month functional outcome after AIS was U-shaped. Both higher SBP and lower SBP lead to poor prognosis in AIS patients.
Collapse
Affiliation(s)
- Manyan Hu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Yuan Zhu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Zhaoyao Chen
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Wenlei Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Li Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Yunze Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Yangjingyi Xia
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Tianrui Zhang
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Qinghua Feng
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Jiacheng Wu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Minghua Wu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China.
| |
Collapse
|
19
|
Samuels N, van de Graaf RA, Mulder MJHL, Brown S, Roozenbeek B, van Doormaal PJ, Goyal M, Campbell BCV, Muir KW, Agrinier N, Bracard S, White PM, Román LS, Jovin TG, Hill MD, Mitchell PJ, Demchuk AM, Bonafe A, Devlin TG, van Es ACGM, Lingsma HF, Dippel DWJ, van der Lugt A. Admission systolic blood pressure and effect of endovascular treatment in patients with ischaemic stroke: an individual patient data meta-analysis. Lancet Neurol 2023; 22:312-319. [PMID: 36931806 DOI: 10.1016/s1474-4422(23)00076-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/06/2023] [Accepted: 02/20/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Current guidelines for ischaemic stroke treatment recommend a strict, but arbitrary, upper threshold of 185/110 mm Hg for blood pressure before endovascular thrombectomy. Nevertheless, whether admission blood pressure influences the effect of endovascular thrombectomy on outcome remains unknown. Our aim was to study the influence of admission systolic blood pressure (SBP) on functional outcome and on the effect of endovascular thrombectomy. METHODS We used individual patient data from seven randomised controlled trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, PISTE, and THRACE) that randomly assigned patients with anterior circulation ischaemic stroke to endovascular thrombectomy (predominantly using stent retrievers) or standard medical therapy (control) between June 1, 2010, and April 30, 2015. We included all patients for whom SBP data were available at hospital admission. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. We assessed the association of SBP with outcome in both the endovascular thrombectomy group and the control group using multilevel regression analysis and tested for non-linearity and for interaction between SBP and effect of endovascular thrombectomy, taking into account treatment with intravenous thrombolysis. FINDINGS We included 1753 patients (867 assigned to endovascular thrombectomy, 886 assigned to control) after excluding 11 patients for whom SBP data were missing. We found a non-linear association between SBP and functional outcome with an inflection point at 140 mm Hg (732 [42%] of 1753 patients had SBP <140 mm Hg and 1021 [58%] had SBP ≥140 mm Hg). Among patients with SBP of 140 mm Hg or higher, admission SBP was associated with worse functional outcome (adjusted common odds ratio [acOR] 0·86 per 10 mm Hg SBP increase; 95% CI 0·81-0·91). We found no association between SBP and functional outcome in patients with SBP less than 140 mm Hg (acOR 0·97 per 10 mm Hg SBP decrease, 95% CI 0·88-1·05). There was no significant interaction between SBP and effect of endovascular thrombectomy on functional outcome (p=0·96). INTERPRETATION In our meta-analysis, high admission SBP was associated with worse functional outcome after stroke, but SBP did not seem to negate the effect of endovascular thrombectomy. This finding suggests that admission SBP should not form the basis for decisions to withhold or delay endovascular thrombectomy for ischaemic stroke, but randomised trials are needed to further investigate this possibility. FUNDING Medtronic.
Collapse
Affiliation(s)
- Noor Samuels
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, Netherlands.
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Maxim J H L Mulder
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Scott Brown
- BRIGHT Research Partners, Mooresville, NC, USA
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Mayank Goyal
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nelly Agrinier
- Centre Hospitalier Régional Universitaire Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University of Lorraine and University Hospital of Nancy, France
| | - Phil M White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Luis San Román
- Neuroradiology Service, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, NJ, USA
| | - Michael D Hill
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew M Demchuk
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alain Bonafe
- Department of Neuroradiology, Centre Hospitalier Universitaire de Montpellier-Guy de Chauliac, Montpellier, France
| | - Thomas G Devlin
- Department of Neurology, University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - Adriaan C G M van Es
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Song L, Yang P, Zhang Y, Zhang X, Chen X, Li Y, Shen H, Zhang L, Li Z, Zhang Y, Xing P, Zhang P, Zhou Y, Ren X, Billot L, Wang X, Parsons MW, Butcher K, Campbell B, Robinson T, Goyal M, Dippel D, Roos Y, Majoie C, Liu J, Anderson CS. The second randomized controlled ENhanced Control of Hypertension ANd Thrombectomy strokE stuDy (ENCHANTED2): Protocol and progress. Int J Stroke 2023; 18:364-369. [PMID: 35924814 DOI: 10.1177/17474930221120345] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Uncertainty exists over the optimal level of blood pressure (BP) after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). OBJECTIVES We aim to determine the effectiveness and safety of intensive BP-lowering following MT reperfusion of large-vessel occlusion (LVO)-related AIS. DESIGN The second ENhanced Control of Hypertension ANd Thrombolysis strokE stuDy (ENCHANTED2) is an investigator-initiated, multicenter, prospective, randomized, open, blinded-endpoint (PROBE) trial of intensive systolic BP (SBP) control in reperfused (extended treatment in cerebral infarction (eTICI) classification 2b/2c/3) LVO-AIS patients with persistent hypertension (SBP ⩾ 140 mmHg) at 60+ sites in China, and Australia and the United Kingdom. Eligible patients are centrally randomly allocated to more- (target SBP ⩽ 120 mmHg within 1 h) or less-intensive (target SBP 140-180 mmHg) BP management, to be maintained for 72 h. Primary outcome is an ordinal shift analysis of scores on the modified Rankin scale (mRS) at 90 days. Sample size of 2257 patients provides 90% power to detect a 6.5% absolute reduction in poor outcome from more-intensive BP-lowering using ordinal logistic regression. PROGRESS Recruitment started in China in July 2020. At a meeting of the independent Data and Safety Monitoring Board in March 2022 to review primary outcome data available for 347 patients, they recommended suspension of recruitment due to safety concerns in the more-intensive group; which was implemented by the Trial Steering Committee (TSC) with 817 randomized patients only in China. The TSC then stopped recruitment after the safety concerns persisted on further review of the data in June 2022. The TSC will make a decision on restarting the trial with modification of the protocol when the results are made public. DISCUSSION ENCHANTED2 will provide further randomized evidence on the role of intensive BP-lowering after reperfusion in MT-treated AIS patients. TRIAL REGISTRATION ClinicalTrials.gov NCT04140110; registered 25 October 2019.
Collapse
Affiliation(s)
- Lili Song
- The George Institute for Global Health China, Beijing, China.,The George Institute for Global Health, Faculty of Medicine, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoxi Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoying Chen
- The George Institute for Global Health China, Beijing, China.,The George Institute for Global Health, Faculty of Medicine, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Yunke Li
- The George Institute for Global Health China, Beijing, China
| | - Hongjian Shen
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zifu Li
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ping Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yihan Zhou
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xinwen Ren
- The George Institute for Global Health China, Beijing, China
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Mark W Parsons
- Ingham Institute for Applied Medical Research, Liverpool Hospital, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Ken Butcher
- Prince of Wales Clinical School, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Bruce Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Mayank Goyal
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Diederik Dippel
- Department of Neurology, Erasmus MC, Rotterdam, The Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Craig S Anderson
- The George Institute for Global Health China, Beijing, China.,The George Institute for Global Health, Faculty of Medicine, The University of New South Wales (UNSW), Sydney, NSW, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | | |
Collapse
|
22
|
Lin CJ, Chung CP, Cheng HM, Liu CH, Hsu LC, Chi NF, Tang SC, Lee JT, Po HL, Jeng JS, Wang TD, Lee IH. The 2020 Taiwan Stroke Society guidelines for blood pressure control at the acute stage of ischemic stroke. J Formos Med Assoc 2023; 122:98-105. [PMID: 36041989 DOI: 10.1016/j.jfma.2022.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 03/11/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023] Open
Abstract
The 2020 Taiwan Stroke Society (TSS) guidelines for blood pressure (BP) control related to ischemic stroke update the 2015 TSS BP guidelines. The early management of acute ischemic stroke has evolved rapidly in the previous two decades. Since the publication of the previous version of the TSS BP guidelines, many studies have addressed BP management in ischemic stroke. Particularly, several successful endovascular thrombectomy (EVT) trials published in 2015 led to a new era of acute treatment for ischemic stroke. With the ever-increasing use of EVT, evidence-based guidelines for ideal BP management during and after EVT are urgently needed. Consequently, the 2020 guidelines are updating and providing recommendations on BP control for the treatment and prevention of ischemic stroke based on new evidence. The present study encompasses the most important chapter of the 2020 Taiwan BP guidelines: BP control at the acute stage of ischemic stroke. We incorporated the most updated evidence regarding BP control at the acute stage of ischemic stroke in patients receiving or not receiving acute reperfusion therapy and provided specific recommendations for different treatment subgroups accordingly.
Collapse
Affiliation(s)
- Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Chih-Ping Chung
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.
| | - Hao-Ming Cheng
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Institute of Public Health, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Center for Evidence-based Medicine & Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chi-Hung Liu
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Li-Chi Hsu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Nai-Fang Chi
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, Taipei, Taiwan
| | - Helen L Po
- Department of Neurology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzung-Dau Wang
- Department of Cardiology, National Taiwan University, Taipei, Taiwan
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| |
Collapse
|
23
|
Gkantzios A, Kokkotis C, Tsiptsios D, Moustakidis S, Gkartzonika E, Avramidis T, Aggelousis N, Vadikolias K. Evaluation of Blood Biomarkers and Parameters for the Prediction of Stroke Survivors' Functional Outcome upon Discharge Utilizing Explainable Machine Learning. Diagnostics (Basel) 2023; 13:diagnostics13030532. [PMID: 36766637 PMCID: PMC9914778 DOI: 10.3390/diagnostics13030532] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023] Open
Abstract
Despite therapeutic advancements, stroke remains a leading cause of death and long-term disability. The quality of current stroke prognostic models varies considerably, whereas prediction models of post-stroke disability and mortality are restricted by the sample size, the range of clinical and risk factors and the clinical applicability in general. Accurate prognostication can ease post-stroke discharge planning and help healthcare practitioners individualize aggressive treatment or palliative care, based on projected life expectancy and clinical course. In this study, we aimed to develop an explainable machine learning methodology to predict functional outcomes of stroke patients at discharge, using the Modified Rankin Scale (mRS) as a binary classification problem. We identified 35 parameters from the admission, the first 72 h, as well as the medical history of stroke patients, and used them to train the model. We divided the patients into two classes in two approaches: "Independent" vs. "Non-Independent" and "Non-Disability" vs. "Disability". Using various classifiers, we found that the best models in both approaches had an upward trend, with respect to the selected biomarkers, and achieved a maximum accuracy of 88.57% and 89.29%, respectively. The common features in both approaches included: age, hemispheric stroke localization, stroke localization based on blood supply, development of respiratory infection, National Institutes of Health Stroke Scale (NIHSS) upon admission and systolic blood pressure levels upon admission. Intubation and C-reactive protein (CRP) levels upon admission are additional features for the first approach and Erythrocyte Sedimentation Rate (ESR) levels upon admission for the second. Our results suggest that the said factors may be important predictors of functional outcomes in stroke patients.
Collapse
Affiliation(s)
- Aimilios Gkantzios
- Department of Neurology, School of Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, 68100 Alexandroupolis, Greece
- Department of Neurology, Korgialeneio—Benakeio “Hellenic Red Cross” General Hospital of Athens, 11526 Athens, Greece
- Correspondence:
| | - Christos Kokkotis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
| | - Dimitrios Tsiptsios
- Department of Neurology, School of Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Serafeim Moustakidis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
- AIDEAS OÜ, Narva mnt 5, 10117 Tallinn, Estonia
| | - Elena Gkartzonika
- School of Philosophy, University of Ioannina, 45110 Ioannina, Greece
| | - Theodoros Avramidis
- Department of Neurology, Korgialeneio—Benakeio “Hellenic Red Cross” General Hospital of Athens, 11526 Athens, Greece
| | - Nikolaos Aggelousis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
| | - Konstantinos Vadikolias
- Department of Neurology, School of Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| |
Collapse
|
24
|
Chen M. JNIS spotlight: commissioned reviews. J Neurointerv Surg 2023; 15:jnis-2022-020019. [PMID: 36593117 DOI: 10.1136/jnis-2022-020019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
25
|
Periprocedure Management of Blood Pressure After Acute Ischemic Stroke. J Neurosurg Anesthesiol 2023; 35:4-9. [PMID: 36441847 DOI: 10.1097/ana.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/30/2022]
Abstract
The management of acute ischemic stroke primarily revolves around the timely restoration of blood flow (recanalization/reperfusion) in the occluded vessel and maintenance of cerebral perfusion through collaterals before reperfusion. Mechanical thrombectomy is the most effective treatment for acute ischemic stroke due to large vessel occlusions in appropriately selected patients. Judicious management of blood pressure before, during, and after mechanical thrombectomy is critical to ensure good outcomes by preventing progression of cerebral ischemia as well hemorrhagic conversion, in addition to optimizing systemic perfusion. While direct evidence to support specific hemodynamic targets around mechanical thrombectomy is limited, there is increasing interest in this area. Newer approaches to blood pressure management utilizing individualized cerebral autoregulation-based targets are being explored. Early efforts at utilizing machine learning to predict blood pressure treatment thresholds and therapies also seem promising; this focused review aims to provide an update on recent evidence around periprocedural blood pressure management after acute ischemic stroke, highlighting its implications for clinical practice while identifying gaps in current literature.
Collapse
|
26
|
Impact of leukoaraiosis or blood pressure on clinical outcome, mortality and symptomatic intracerebral hemorrhage after mechanical thrombectomy in acute ischemic stroke. Sci Rep 2022; 12:21750. [PMID: 36526650 PMCID: PMC9758212 DOI: 10.1038/s41598-022-25171-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022] Open
Abstract
We aimed to study the impact of leukoaraiosis (LA) and blood pressure (BP) on clinical outcome, mortality and symptomatic intracerebral hemorrhage (sICH) in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). We analyzed data retrospectively from 521 patients with anterior large vessel occlusion treated with MT. LA was dichotomized in 0-2 (absent-to-moderate) versus 3-4 (moderate-to-severe) according to the van Swieten scale. Various systolic (SBP) and diastolic (DBP) BP parameters during the first 24 h were collected. Multivariable logistic regressions were performed to identify predictors of a poor 90-day outcome, mortality and sICH. LA was significantly associated with poor outcome (OR 3.2; p < 0.001) and mortality (OR 3.19; p = 0.008), but not sICH (p = 0.19). Higher maximum SBP was significantly associated with poor outcome (OR per 10 mmHg increase = 1.21; p = 0.009) and lower mean DBP was a predictor of mortality (OR per 10 mmHg increase = 0.53; p < 0.001). In the univariate analysis high SBP variability was associated with poor outcome, mortality and sICH, but not in the multivariate model. There was no association between BP and sICH. Severity of LA, SBP variability, high maximum SBP and low DBP are associated with either poor outcome or mortality in AIS patients undergoing MT. However, neither LA nor BP were associated with sICH in our cohort. Thus, mechanisms of the negative impact on outcome remain unclear. Further studies on impact of BP course and its mechanisms and interventions are needed to improve outcome in patients undergoing MT.
Collapse
|
27
|
Yang P, Song L, Zhang Y, Zhang X, Chen X, Li Y, Sun L, Wan Y, Billot L, Li Q, Ren X, Shen H, Zhang L, Li Z, Xing P, Zhang Y, Zhang P, Hua W, Shen F, Zhou Y, Tian B, Chen W, Han H, Zhang L, Xu C, Li T, Peng Y, Yue X, Chen S, Wen C, Wan S, Yin C, Wei M, Shu H, Nan G, Liu S, Liu W, Cai Y, Sui Y, Chen M, Zhou Y, Zuo Q, Dai D, Zhao R, Li Q, Huang Q, Xu Y, Deng B, Wu T, Lu J, Wang X, Parsons MW, Butcher K, Campbell B, Robinson TG, Goyal M, Dippel D, Roos Y, Majoie C, Wang L, Wang Y, Liu J, Anderson CS. Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet 2022; 400:1585-1596. [PMID: 36341753 DOI: 10.1016/s0140-6736(22)01882-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The optimum systolic blood pressure after endovascular thrombectomy for acute ischaemic stroke is uncertain. We aimed to compare the safety and efficacy of blood pressure lowering treatment according to more intensive versus less intensive treatment targets in patients with elevated blood pressure after reperfusion with endovascular treatment. METHODS We conducted an open-label, blinded-endpoint, randomised controlled trial at 44 tertiary-level hospitals in China. Eligible patients (aged ≥18 years) had persistently elevated systolic blood pressure (≥140 mm Hg for >10 min) following successful reperfusion with endovascular thrombectomy for acute ischaemic stroke from any intracranial large-vessel occlusion. Patients were randomly assigned (1:1, by a central, web-based program with a minimisation algorithm) to more intensive treatment (systolic blood pressure target <120 mm Hg) or less intensive treatment (target 140-180 mm Hg) to be achieved within 1 h and sustained for 72 h. The primary efficacy outcome was functional recovery, assessed according to the distribution in scores on the modified Rankin scale (range 0 [no symptoms] to 6 [death]) at 90 days. Analyses were done according to the modified intention-to-treat principle. Efficacy analyses were performed with proportional odds logistic regression with adjustment for treatment allocation as a fixed effect, site as a random effect, and baseline prognostic factors, and included all randomly assigned patients who provided consent and had available data for the primary outcome. The safety analysis included all randomly assigned patients. The treatment effects were expressed as odds ratios (ORs). This trial is registered at ClinicalTrials.gov, NCT04140110, and the Chinese Clinical Trial Registry, 1900027785; recruitment has stopped at all participating centres. FINDINGS Between July 20, 2020, and March 7, 2022, 821 patients were randomly assigned. The trial was stopped after review of the outcome data on June 22, 2022, due to persistent efficacy and safety concerns. 407 participants were assigned to the more intensive treatment group and 409 to the less intensive treatment group, of whom 404 patients in the more intensive treatment group and 406 patients in the less intensive treatment group had primary outcome data available. The likelihood of poor functional outcome was greater in the more intensive treatment group than the less intensive treatment group (common OR 1·37 [95% CI 1·07-1·76]). Compared with the less intensive treatment group, the more intensive treatment group had more early neurological deterioration (common OR 1·53 [95% 1·18-1·97]) and major disability at 90 days (OR 2·07 [95% CI 1·47-2·93]) but there were no significant differences in symptomatic intracerebral haemorrhage. There were no significant differences in serious adverse events or mortality between groups. INTERPRETATION Intensive control of systolic blood pressure to lower than 120 mm Hg should be avoided to prevent compromising the functional recovery of patients who have received endovascular thrombectomy for acute ischaemic stroke due to intracranial large-vessel occlusion. FUNDING The Shanghai Hospital Development Center; National Health and Medical Research Council of Australia; Medical Research Futures Fund of Australia; China Stroke Prevention; Shanghai Changhai Hospital, Science and Technology Commission of Shanghai Municipality; Takeda China; Hasten Biopharmaceutic; Genesis Medtech; Penumbra.
Collapse
Affiliation(s)
- Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China; Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lili Song
- The George Institute for Global Health China, Beijing, China; Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China; Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoxi Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoying Chen
- The George Institute for Global Health China, Beijing, China; Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Yunke Li
- The George Institute for Global Health China, Beijing, China
| | - Lingli Sun
- The George Institute for Global Health China, Beijing, China
| | - Yingfeng Wan
- The George Institute for Global Health China, Beijing, China
| | - Laurent Billot
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Qiang Li
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Xinwen Ren
- The George Institute for Global Health China, Beijing, China
| | - Hongjian Shen
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zifu Li
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ping Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Weilong Hua
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Fang Shen
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yihan Zhou
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bing Tian
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Wenhuo Chen
- Department of Neurointervention, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Linyi, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Chenghua Xu
- Department of Neurology, Taizhou First People's Hospital, Taizhou, China
| | - Tong Li
- Department of Neurology, The Second People's Hospital of Nanning, Nanning, China
| | - Ya Peng
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, China
| | - Xincan Yue
- Neurosurgical Intensive Care Unit, Zhoukou Central Hospital, Zhoukou, China
| | - Shengli Chen
- Department of Neurology, Chongqing Three Gorges University Hospital, Chongqing, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital of Xinxiang Medical University, Nanyang, China
| | - Shu Wan
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Congguo Yin
- Department of Neurology, Hangzhou First People's Hospital, Hangzhou, China
| | - Ming Wei
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Hansheng Shu
- Department of Neurosurgery, The Second Affiliated Hospital of Beng Bu Medical College, Bengbu, China
| | - Guangxian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wenhua Liu
- Department of Neurology, Wuhan No 1 Hospital, Wuhan, China
| | - Yiling Cai
- Department of Neurology, Strategic Support Force Medical Center, Beijing, China
| | - Yi Sui
- Department of Neurology, Shenyang First People's Hospital, Shenyang Brain Institute, Shenyang, China
| | - Maohua Chen
- Department of Neurosurgery, Wenzhou Central Hospital, Wenzhou, China
| | - Yu Zhou
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiao Zuo
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Dongwei Dai
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Rui Zhao
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiang Li
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yi Xu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Benqiang Deng
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Tao Wu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianping Lu
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xia Wang
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Mark W Parsons
- Ingham Institute for Applied Medical Research, Liverpool Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Ken Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Bruce Campbell
- Melbourne Brain Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health and Care Research Leicester Biomedical Research Centre, Leicester, UK
| | - Mayank Goyal
- Department of Radiology and Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Diederik Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Longde Wang
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China
| | - Yongjun Wang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China; Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China.
| | - Craig S Anderson
- The George Institute for Global Health China, Beijing, China; Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| |
Collapse
|
28
|
Xiaoxi Z, Xuan Z, Lei Z, Zifu L, Pengfei X, Hongjian S, Yongxin Z, Weilong H, Yihan Z, Dongwei D, Qiang L, Rui Z, Qinghai H, Yi X, Song L, Anderson CS, Jianmin L, Yongwei Z, Pengfei Y. Baseline blood pressure does not modify the effect of intravenous thrombolysis in successfully revascularized patients. Front Neurol 2022; 13:984599. [PMID: 36172030 PMCID: PMC9510834 DOI: 10.3389/fneur.2022.984599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundStudies indicate a trajectory relationship between baseline blood pressure (BP) and outcome in patients with acute ischemic stroke (AIS) eligible for both intravenous thrombolysis (IVT) with alteplase and endovascular treatment (EVT). We determined whether baseline BP modified the effect of IVT in successfully revascularized AIS patients who participated in the Direct Intra-Arterial Thrombectomy to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals (DIECT-MT) trial.MethodsThe association of baseline systolic BP, trichotomized as high (141–185 mmHg), middle (121–140 mmHg), and low (91–120 mmHg), and the outcomes of any intracerebral hemorrhage (ICH), symptomatic ICH (sICH), and mortality and functional outcome on the modified Rankin scale at 90 days were explored. Logistic regression models determined the interaction between clinical outcomes and baseline systolic and diastolic BP, and mean arterial pressure (MAP), at 10 mmHg intervals. Data are reported as odds ratios (OR) and 95% CI.ResultsA post-hoc analysis of DIRECT-MT, in 510 of the 656 randomized participants with successful revascularization underwent MT. The overall adjusted common OR of IVT and baseline BP on any ICH, sICH, and 90-day mortality and functional outcome were 0.884 (95%CI 0.613–1.274), 0.643 (95%CI 0.283–1.458), 0.842 (95%CI 0.566–1.252), and 1.286 (95%CI 0.772–2.142), respectively. No significant interaction between baseline blood pressure and intravenous thrombolysis with clinical outcome was observed.ConclusionsIn patients with baseline SBP under 185 mmHg, baseline blood pressure does not alter the risk of hemorrhagic transformation and clinicaloutcome in successfully revascularized patients, regardless of intravenous alteplase usage. Future studies are needed to confirm our findings.RegistrationURL: http://www.clinicaltrials.gov, Identifier: NCT03469206.
Collapse
Affiliation(s)
- Zhang Xiaoxi
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhu Xuan
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhang Lei
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Li Zifu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xing Pengfei
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shen Hongjian
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhang Yongxin
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Hua Weilong
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhou Yihan
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Dai Dongwei
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Li Qiang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhao Rui
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Huang Qinghai
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xu Yi
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lili Song
- Global Brain Health, The George Institute for Global Health, Beijing, China
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Stroke Program, The George Institute for Global Health, Beijing, China
- Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Liu Jianmin
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhang Yongwei
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
- *Correspondence: Zhang Yongwei
| | - Yang Pengfei
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
- Yang Pengfei
| |
Collapse
|
29
|
Vilionskis A, Gaigalaite V, Salasevicius L, Jatuzis D. Association between systolic blood pressure parameters and unexplained early neurological deterioration (UnND) in acute ischemic stroke patients treated with mechanical thrombectomy. Ther Adv Neurol Disord 2022; 15:17562864221093524. [PMID: 35747319 PMCID: PMC9210098 DOI: 10.1177/17562864221093524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Neurological deterioration (ND) after mechanical thrombectomy (MT) of acute ischemic stroke (AIS) in anterior circulation is an important complication associated with a poor outcome. Moreover, evident causes of ND may remain unexplained (UnND). Objective: We sought to evaluate the association of the systolic blood pressure (SBP) parameters before MT, during MT, and during a 24-h period after MT with UnND. Methods: We analyzed 382 MT-treated AIS patients in two stroke centers from 2017 to 2019. The patients with unsuccessful recanalization and/or with symptomatic intracerebral hemorrhage after MT were excluded. Multivariate logistic regression analysis was used to identify the SBP parameters that predict UnND. Results: There were 5.9% patients with UnND within 24 h after MT among patients with successful recanalization what comprises 4.9% of all patients who had undergone MT. SBP > 180 mmHg on admission (odds ratio (OR): 4, 95% confidence interval (CI): 1.6–10, p = 0.004) and a drop of SBP below100 mmHg during MT (OR: 4.7, 95% CI: 1.3–17, p = 0.019) were associated with UnND occurrence within 7 days without a significant association with UnND within 24 h. UnND within 7 days was predicted by the episodes of SBP exceeding the level of SBP observed before the groin puncture and occurring over the first 2 h following recanalization (OR: 5, 95% CI: 1.3–19, p = 0.021), an increase of SBP of more than 20% within 2–24 h after MT (OR: 3.4, 95% CI: 1.1–10, p = 0.035), and a drop of SBP below 100 mmHg after MT (OR: 3.2, 95% CI: 1.1–9, p = 0.039). Conclusion: The association between the SBP parameters and UnND depends on the treatment period and the time of UnND occurrence. The J/U resembling relationship between SBP and UnEND was established during a 24-h period after MT.
Collapse
Affiliation(s)
| | - Virginija Gaigalaite
- Institute of Clinical Medicine, Vilnius University, Siltnamiu 29, Vilnius 01513, Lithuania
| | | | - Dalius Jatuzis
- Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| |
Collapse
|
30
|
Cao Y, Li R, Jiang S, Guo J, Luo X, Miao J, Liu J, Zheng B, Du J, Zhang Y, Yang S, Wang L, Zi W, Yang Q, Luo J, Jiang G. The Relationship Between Admission Blood Pressure and Clinical Outcomes for Acute Basilar Artery Occlusion. Front Neurosci 2022; 16:900868. [PMID: 35801181 PMCID: PMC9253464 DOI: 10.3389/fnins.2022.900868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background and Purpose Optimal blood pressure management of patients with basilar artery occlusion (BAO) remains uncertain. This study aimed to investigate the relationship between admission blood pressure and clinical outcomes following acute BAO. Materials and Methods We analyzed data from a prospective, nationwide cohort study of 829 patients with acute BAO and posterior circulation stroke. Baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded on admission. The primary outcome was neurological functional disability based on the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included successful reperfusion, mortality within 90 days, and National Institutes of Health Stroke Scale (NIHSS) score change. Multivariable logistic regression was used to assess the associations of SBP and DBP with outcomes. Results We include 829 patients with posterior circulation stroke and BAO between January 2014 and May 2019. Multivariate logistic regression showed high SBP and DBP correlated with unfavorable outcomes. The favorable prognosis (mRS ≤ 3) rates of the low-to-normal and the hypertension groups were 34.8 and 23.9%, respectively. After adjusting for covariates, multivariate regression analysis demonstrated that an SBP > 140 mm Hg was associated with a poor functional outcome [adjusted OR (aOR), 1.509; 95% CI, 1.130–2.015] and mortality at 90 days (aOR, 1.447; 95% CI, 1.055–1.985), and predicted a lower probability of successful reperfusion (aOR, 0.550; 95% CI, 0.389–0.778). The risk of symptomatic intracranial hemorrhage and the NIHSS score at 24 h were not significantly different between the high SBP group and the low-to-normal blood pressure group. And the results for DBP were similar. Conclusion Among patients with acute BAO, higher systolic or DBP at admission was associated with poor stroke outcomes and had a lower probability of successful reperfusion, with an increased risk of mortality. Trail Registration: [http://www.chictr.org.cn], [ChiCTR1800014759].
Collapse
Affiliation(s)
- Yuhong Cao
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Rongzong Li
- Department of Neurology, The 924th Hospital of PLA, Guilin, China
| | - Shunfu Jiang
- Department of Neurology, Jingdezhen First People’s Hospital, Jingdezhen, China
| | - Jing Guo
- Department of Neurology, Chongqing University Three Gorges Central Hospital, Chongqing, China
| | - Xiaojun Luo
- Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, China
| | - Jian Miao
- Department of Neurology, Xianyang Hospital of Yan’an University, Xianyang, China
| | - Jincheng Liu
- Department of Neurology, The First People’s Hospital of Xiangyang, Hubei Medical University, Xiangyang, China
| | - Bo Zheng
- Department of Neurology, Ya’an People’s Hospital, Ya’an, China
| | - Jie Du
- Department of Neurology, Kaizhou District People’s Hospital, Chongqing, China
| | - Yuxian Zhang
- Department of Neurology, Danzhai County People’s Hospital, Danzhai, China
| | - Shunyu Yang
- Department of Neurology, The First People’s Hospital of Yunnan Provience, Kunming, China
| | - Li Wang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jun Luo
- Department of Neurology, Sichuan Mianyang 404 Hospital, Mianyang, China
- Jun Luo,
| | - Guohui Jiang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
- *Correspondence: Guohui Jiang,
| |
Collapse
|
31
|
Farag E, Argalious M, Toth G. Stroke thrombectomy perioperative anesthetic and hemodynamic management. J Neurointerv Surg 2022; 15:483-487. [PMID: 35697516 DOI: 10.1136/neurintsurg-2021-018300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/21/2022] [Indexed: 11/04/2022]
Abstract
There is an ongoing debate about the optimal anesthetic and hemodynamic management of acute stoke patients with large vessel occlusion undergoing endovascular mechanical thrombectomy. Several prospective and retrospective analyses, and randomized controlled trials, attempted to address the challenges of using different anesthetic modalities in acute stroke patients requiring mechanical thrombectomy. We review the advantages and disadvantages of monitored anesthesia care, local anesthesia, conscious sedation, and general anesthesia, along with the relevance of hemodynamic management and perioperative oxygenation status in these complex patients.
Collapse
Affiliation(s)
- Ehab Farag
- Department of General Anesthesia, Anesthesiology and Pain Management Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Outcomes Research, Anesthesiology and Pain Management Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Maged Argalious
- Department of General Anesthesia, Anesthesiology and Pain Management Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
32
|
Abada A, Csecsei P, Ezer E, Lenzser G, Hegyi P, Szolics A, Merei A, Szentesi A, Molnar T. General Anesthesia-Related Drop in Diastolic Blood Pressure May Impact the Long-Term Outcome in Stroke Patients Undergoing Thrombectomy. J Clin Med 2022; 11:jcm11112997. [PMID: 35683386 PMCID: PMC9181773 DOI: 10.3390/jcm11112997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Several factors affect the efficacy of endovascular thrombectomy (EVT); however, the anesthesia-related factors have not been fully explored. We aimed to identify independent predictors of outcome by analyzing procedural factors based on a multicentric stroke registry. Methods: Data of consecutive patients with acute ischemic stroke (AIS) were extracted from the prospective STAY ALIVE stroke registry. Demographic, clinical, and periprocedural factors including hemodynamic values were analyzed in patients undergoing thrombectomy with either general anesthesia (GA) or conscious sedation (CS). Independent predictors of outcome both at 30 and 90 days based on the modified Rankin Scale (mRS: 0−2 as favorable outcome) were also explored. Results: A total of 199 patients (GA: 76 (38%) vs. CS: 117 (59%); in addition, six patients were converted from CS to GA) were included. The minimum value of systolic, diastolic, and mean arterial pressure was significantly lower in the GA compared to the CS group, and GA was associated with a longer onset to EVT time and a higher drop in all hemodynamic variables (all, p < 0.001). A higher drop in diastolic blood pressure (DBP) was even independently associated with a poor 90-day outcome (p = 0.024). Conclusion: A GA-related drop in DBP may independently predict a poor long-term outcome in stroke patients undergoing thrombectomy.
Collapse
Affiliation(s)
- Alan Abada
- Department of Anesthesiology and Intensive Care, Medical School, University of Pecs, 7624 Pecs, Hungary; (A.A.); (E.E.); (A.M.); (T.M.)
- Centre for Translational Medicine, Semmelweiss University, 1085 Budapest, Hungary; (P.H.); (A.S.)
| | - Peter Csecsei
- Department of Neurosurgery, Medical School, University of Pecs, 7624 Pecs, Hungary;
- Correspondence: or ; Tel.: +36-7256590037704
| | - Erzsebet Ezer
- Department of Anesthesiology and Intensive Care, Medical School, University of Pecs, 7624 Pecs, Hungary; (A.A.); (E.E.); (A.M.); (T.M.)
| | - Gabor Lenzser
- Department of Neurosurgery, Medical School, University of Pecs, 7624 Pecs, Hungary;
| | - Peter Hegyi
- Centre for Translational Medicine, Semmelweiss University, 1085 Budapest, Hungary; (P.H.); (A.S.)
| | - Alex Szolics
- Department of Radiology, Örebro University Hospital, 70281 Örebro, Sweden;
| | - Akos Merei
- Department of Anesthesiology and Intensive Care, Medical School, University of Pecs, 7624 Pecs, Hungary; (A.A.); (E.E.); (A.M.); (T.M.)
| | - Andrea Szentesi
- Centre for Translational Medicine, Semmelweiss University, 1085 Budapest, Hungary; (P.H.); (A.S.)
| | - Tihamer Molnar
- Department of Anesthesiology and Intensive Care, Medical School, University of Pecs, 7624 Pecs, Hungary; (A.A.); (E.E.); (A.M.); (T.M.)
| |
Collapse
|
33
|
Petersen NH, Kodali S, Meng C, Li F, Nguyen CK, Peshwe KU, Strander S, Silverman A, Kimmel A, Wang A, Anadani M, Almallouhi E, Spiotta AM, Kim JT, Giles JA, Keyrouz SG, Farooqui M, Zevallos C, Maier IL, Psychogios MN, Liman J, Riou-Comte N, Richard S, Gory B, Wolfe SQ, Brown PA, Fargen KM, Mistry EA, Fakhri H, Mistry AM, Wong KH, de Havenon A, Nascimento FA, Kan P, Matouk C, Ortega-Gutiérrez S, Sheth KN. Blood Pressure Trajectory Groups and Outcome After Endovascular Thrombectomy: A Multicenter Study. Stroke 2022; 53:1216-1225. [PMID: 34781705 PMCID: PMC8960326 DOI: 10.1161/strokeaha.121.034408] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes. METHODS This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the modified Rankin Scale 90 days after stroke. Secondary outcomes included hemorrhagic transformation, symptomatic intracranial hemorrhage, and death. RESULTS Two thousand two hundred sixty-eight patients (mean age [±SD] 69±15, mean National Institutes of Health Stroke Scale 15±7) were included in the analysis. Five distinct SBP trajectories were observed: low (18%), moderate (37%), moderate-to-high (20%), high-to-moderate (18%), and high (6%). SBP trajectory group was independently associated with functional outcome at 90 days (P<0.0001) after adjusting for potential confounders. Patients with high and high-to-moderate SBP trajectories had significantly greater odds of an unfavorable outcome (adjusted odds ratio, 3.5 [95% CI, 1.8-6.7], P=0.0003 and adjusted odds ratio, 2.2 [95% CI, 1.5-3.2], P<0.0001, respectively). Subjects in the high-to-moderate group had an increased risk of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.82 [95% CI, 1-3.2]; P=0.04). No significant association was found between trajectory group and hemorrhagic transformation. CONCLUSIONS Patients with acute ischemic stroke demonstrate distinct SBP trajectories during the first 72 hours after EVT that have differing associations with functional outcome. These findings may help identify potential candidates for future blood pressure modulation trials.
Collapse
Affiliation(s)
- Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Sreeja Kodali
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Can Meng
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT
| | - Fangyong Li
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT
| | - Cindy Khanh Nguyen
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Krithika U. Peshwe
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Sumita Strander
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Andrew Silverman
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Alexandra Kimmel
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Anson Wang
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Mohammad Anadani
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Eyad Almallouhi
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Alejandro M. Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
| | - James A. Giles
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Salah G. Keyrouz
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Cynthia Zevallos
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Ilko L. Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Marios-Nikos Psychogios
- Department of Diagnostic and Interventional Neuroradiology, University Clinic Basel, Switzerland
| | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Sébastien Richard
- Department of Neurology, University Hospital of Nancy, Nancy, France,,Centre d’Investigation Clinique Plurithématique, INSERM U1116, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Benjamin Gory
- Department of Neuroradiology, University Hospital of Nancy, Nancy, France,,IADI, INSERM U1254, University of Lorraine, Nancy, France
| | | | - Patrick A. Brown
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kyle M. Fargen
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Eva A. Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Hiba Fakhri
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Ka-Ho Wong
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT
| | - Adam de Havenon
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Peter Kan
- Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
34
|
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.
Collapse
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.)
| |
Collapse
|
35
|
Strømsnes TA, Kaugerud Hagen TJ, Ouyang M, Wang X, Chen C, Rygg SE, Hewson D, Lenthall R, McConachie N, Izzath W, Bath PM, Dhillon PS, Podlasek A, England T, Sprigg N, Robinson TG, Advani R, Ihle-Hansen H, Sandset EC, Krishnan K. Pressor therapy in acute ischaemic stroke: an updated systematic review. Eur Stroke J 2022; 7:99-116. [PMID: 35647316 PMCID: PMC9134777 DOI: 10.1177/23969873221078136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/17/2022] [Indexed: 11/15/2022] Open
Abstract
Background Low blood pressure (BP) in acute ischaemic stroke (AIS) is associated with poor functional outcome, death, or severe disability. Increasing BP might benefit patients with post-stroke hypotension including those with potentially salvageable ischaemic penumbra. This updated systematic review considers the present evidence regarding the use of vasopressors in AIS. Methods We searched the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and trial databases using a structured search strategy. We examined reference lists of relevant publications for additional studies examining BP elevation in AIS. Results We included 27 studies involving 1886 patients. Nine studies assessed increasing BP during acute reperfusion therapy (intravenous thrombolysis, mechanical thrombectomy, intra-arterial thrombolysis or combined). Eighteen studies tested BP elevation alone. Phenylephrine was the most commonly used agent to increase BP (n = 16 studies), followed by norepinephrine (n = 6), epinephrine (n = 3) and dopamine (n = 2). Because of small patient numbers and study heterogeneity, a meta-analysis was not possible. Overall, BP elevation was feasible in patients with fluctuating or worsening neurological symptoms, large vessel occlusion with labile BP, sustained post-stroke hypotension and ineligible for intravenous thrombolysis or after acute reperfusion therapy. The effects on functional outcomes were largely unknown and close monitoring is advised if such intervention is undertaken. Conclusion Although theoretical arguments support increasing BP to improve cerebral blood flow and sustain the ischaemic penumbra in selected AIS patients, the data are limited and results largely inconclusive. Large, randomised controlled trials are needed to identify the optimal BP target, agent, duration of treatment and effects on clinical outcomes.
Collapse
Affiliation(s)
- Torbjørn Austveg Strømsnes
- Department of Neurosurgery, Oslo University hospital, Norway
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Clinical Medicine, University of Bergen, Norway
| | - Truls Jørgen Kaugerud Hagen
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Geriatric Medicine, Oslo University hospital, Norway
| | - Menglu Ouyang
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
| | - Xia Wang
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
| | - Chen Chen
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
- The George Institute for Global Health, Peking University Health Science Center, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Silje-Emilie Rygg
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Geriatric Medicine, Oslo University hospital, Norway
| | - David Hewson
- Department of Anaesthesia, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rob Lenthall
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Norman McConachie
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Wazim Izzath
- Department of Neuroradiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Philip M Bath
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
| | - Permesh Singh Dhillon
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Anna Podlasek
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Timothy England
- Department of Stroke Medicine, Royal Derby Hospital, Derby, UK
| | - Nikola Sprigg
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
| | - Thompson G Robinson
- College of Life Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Rajiv Advani
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
| | - Hege Ihle-Hansen
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
| | - Else Charlotte Sandset
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Norwegian Air Ambulance Foundation, Norway
| | - Kailash Krishnan
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
| |
Collapse
|
36
|
Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
37
|
A Review of Risk Factors and Predictors for Hemorrhagic Transformation in Patients with Acute Ischemic Stroke. Int J Vasc Med 2021; 2021:4244267. [PMID: 34912581 PMCID: PMC8668348 DOI: 10.1155/2021/4244267] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 12/26/2022] Open
Abstract
Acute ischemic strokes (AIS) and hemorrhagic strokes lead to disabling neuropsychiatric and cognitive deficits. A serious and fatal complication of AIS is the occurrence of hemorrhagic transformation (HT). HT is cerebral bleeding that occurs after an ischemic event in the infarcted areas. This review summarises how specific risk factors such as demographic factors like age, gender, and race/ethnicity, comorbidities including essential hypertension, atrial fibrillation, diabetes mellitus, congestive heart failure, and ischemic heart disease along with predictors like higher NIHSS score, larger infarction size, cardioembolic strokes, systolic blood pressure/pulse pressure variability, higher plasma glucose levels, and higher body temperature during ischemic event, lower low-density lipoprotein and total cholesterol, early ischemic changes on imaging modalities, and some rare causes make an individual more susceptible to developing HT. We also discuss few other risk factors such as the role of blood-brain barrier, increased arterial stiffness, and globulin levels in patients postreperfusion using thrombolysis and mechanical thrombectomy. In addition, we discuss the implications of dual antiplatelet therapy and the length of treatment in reference to the incidence of developing HT. Current research into inflammatory mediators and biomarkers such as Cyclooxygenase-2, matrix metalloproteinases, and soluble ST2 and their potential role as treatment options for HT is also briefly discussed. Finally, this review calls for more research into use of dual antiplatelet and the timing of antiplatelet and anticoagulant use in reference to hemorrhagic transformation.
Collapse
|
38
|
Matusevicius M, Cooray C, Holmin S, Bottai M, Ahmed N. Association between systolic blood pressure course and outcomes after stroke thrombectomy. BMJ Neurol Open 2021; 3:e000183. [PMID: 34870205 PMCID: PMC8603273 DOI: 10.1136/bmjno-2021-000183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022] Open
Abstract
Background Systolic blood pressure (SBP) after endovascular thrombectomy (EVT) for large artery occlusive stroke is dynamic, requiring adaptable early prediction tools for improving outcomes. We investigated if post-EVT SBP course was associated with outcomes. Methods EVT-treated patients who had a stroke at Karolinska University Hospital, Stockholm, Sweden, were included in the study during 12 February 2018–11 February 2020. SBP was recorded during the first 24 hours after EVT. Primary outcome was functional independence defined by a Modified Rankin Scale score of 0–2 at 3 months. Secondary outcomes were death by 3 months, symptomatic intracranial haemorrhage and any intracranial haemorrhage. Patients with favourable outcomes were used as a reference SBP course in mixed linear effects models and compared with SBP courses of patients with unfavourable outcomes using the empirical best linear unbiased predictor, measuring deviations from the reference SBP course using the random effects. We tested model predictive stability for SBP measurements of only 18, 12 or 6 hours after EVT. Results 374 patients were registered, with mean age 71, median NIHSS score of 15, and 53.2% men. Deviating from a linear SBP course starting at 130 mm Hg and decreasing to 123 mm Hg at 24 hours after EVT was associated with lower chances of functional independence (adjusted OR 0.53, 95% CI 0.29 to 0.88, for reaching either 99 or 147 mm Hg at 24 hours after EVT). All SBP course models for the remaining outcomes did not show statistical significance. Functional independence models showed stable predictive values for all time periods. Conclusion Deviating from a linear SBP course was associated with lower chances of 3-month functional independence.
Collapse
Affiliation(s)
- Marius Matusevicius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
| | - Charith Cooray
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
39
|
Tian B, Tian X, Shi Z, Peng W, Zhang X, Yang P, Li Z, Zhang X, Lou M, Yin C, Zhang Y, Lu J, Liu J. Clinical and Imaging Indicators of Hemorrhagic Transformation in Acute Ischemic Stroke After Endovascular Thrombectomy. Stroke 2021; 53:1674-1681. [PMID: 34872341 DOI: 10.1161/strokeaha.121.035425] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Prior studies have investigated the clinical and imaging factors for hemorrhagic transformation (HT), especially symptomatic intracranial hemorrhage (sICH); however, whether alteplase increases the risk of HT after endovascular thrombectomy (EVT) is unknown. This study aimed to assess clinical and imaging features associated with HT, sICH, and parenchymal hematoma (PH) in patients with acute ischemic stroke after EVT, with and without intravenous alteplase in DIRECT-MT (Direct Intraarterial Thrombectomy to Revascularize Acute Ischemic Stroke Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals: a Multicenter Randomized Clinical Trial). METHODS The DIRECT-MT trial is a randomized trial of EVT alone versus intravenous thrombolysis combined with EVT. HT, sICH, and PH was evaluated on follow-up computed tomography. Multivariable ordinal logistic regression analysis was used to test the association of stepwise selected determinants with HT, sICH, and PH. RESULTS In total, 633 patients were analyzed; 261 (41.2%) had HT; 34 (5.4%) had sICH; and 85 (13.4%) had PH. The median age was 69, and 56.7% were men. The median National Institutes of Health Stroke Scale score was 18, and 320 patients were in combination-therapy group. Symptomatic intracranial hemorrhage was associated with higher baseline National Institutes of Health Stroke Scale score (adjusted odds ratio [OR], 1.06 [95% CI, 1.10-1.12]) and higher glucose level at hospital arrival (adjusted OR, 1.14 [95% CI, 1.00-1.29]). No association was found between alteplase treatment and HT, sICH, or PH. The independent predictor of sICH was higher baseline National Institutes of Health Stroke Scale score (adjusted OR, 1.09 [95% CI, 1.01-1.18]) in EVT alone group, and history of anticoagulant drugs (adjusted OR, 3.75 [95% CI, 1.07-13.06]), higher glucose level at hospital arrival (adjusted OR, 1.19 [95% CI, 1.03-1.38]), >3 passes of device (adjusted OR, 4.42 [95% CI, 1.36-14.32]) in combination-therapy group. CONCLUSIONS In DIRECT-MT, independent predictors of sICH were baseline National Institutes of Health Stroke Scale score and glucose level at hospital arrival. Alteplase treatment did not increase the risk of HT, sICH, or PH after EVT. The independent predictor of sICH was different in EVT alone group and combination-therapy group. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03469206.
Collapse
Affiliation(s)
- Bing Tian
- Department of Radiology, Changhai hospital of Shanghai, China. (B.T., X.T., Z.S., W.P., Xuefeng Zhang, J. Lu)
| | - Xia Tian
- Department of Radiology, Changhai hospital of Shanghai, China. (B.T., X.T., Z.S., W.P., Xuefeng Zhang, J. Lu)
| | - Zhang Shi
- Department of Radiology, Changhai hospital of Shanghai, China. (B.T., X.T., Z.S., W.P., Xuefeng Zhang, J. Lu)
| | - Wenjia Peng
- Department of Radiology, Changhai hospital of Shanghai, China. (B.T., X.T., Z.S., W.P., Xuefeng Zhang, J. Lu)
| | - Xuefeng Zhang
- Department of Radiology, Changhai hospital of Shanghai, China. (B.T., X.T., Z.S., W.P., Xuefeng Zhang, J. Lu)
| | - Pengfei Yang
- Neurovascular Center, Changhai hospital of Shanghai, China. (P.Y., Z.L., Xiaoxi Zhang, J. Liu)
| | - Zifu Li
- Neurovascular Center, Changhai hospital of Shanghai, China. (P.Y., Z.L., Xiaoxi Zhang, J. Liu)
| | - Xiaoxi Zhang
- Neurovascular Center, Changhai hospital of Shanghai, China. (P.Y., Z.L., Xiaoxi Zhang, J. Liu)
| | - Min Lou
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, China (M.L.)
| | - Congguo Yin
- Department of Neurology, Hangzhou First People's Hospital of Zhejiang University, China (C.Y.)
| | - Yongwei Zhang
- Neurovascular Center, Changhai hospital of Shanghai, China. (Y.Z.)
| | - Jianping Lu
- Department of Radiology, Changhai hospital of Shanghai, China. (B.T., X.T., Z.S., W.P., Xuefeng Zhang, J. Lu)
| | - Jianmin Liu
- Neurovascular Center, Changhai hospital of Shanghai, China. (P.Y., Z.L., Xiaoxi Zhang, J. Liu)
| | | |
Collapse
|
40
|
Chen M, Kronsteiner D, Pfaff J, Schieber S, Jäger L, Bendszus M, Kieser M, Möhlenbruch MA, Ringleb PA, Bösel J, Schönenberger S. Hemodynamic Status During Endovascular Stroke Treatment: Association of Blood Pressure with Functional Outcome. Neurocrit Care 2021; 35:825-834. [PMID: 34142339 PMCID: PMC8692300 DOI: 10.1007/s12028-021-01229-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/06/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Optimal blood pressure (BP) management during endovascular stroke treatment in patients with large-vessel occlusion is not well established. We aimed to investigate associations of BP during different phases of endovascular therapy with reperfusion and functional outcome. METHODS We performed a post hoc analysis of a single-center prospective study that evaluated a new simplified procedural sedation standard during endovascular therapy (Keep Evaluating Protocol Simplification in Managing Periinterventional Light Sedation for Endovascular Stroke Treatment). BP during endovascular therapy in patients was managed according to protocol. Data from four different phases (baseline, pre-recanalization, post recanalization, and post intervention) were obtained, and mean BP values, as well as changes in BP between different phases and reductions in systolic BP (SBP) and mean arterial pressure (MAP) from baseline to pre-recanalization, were used as exposure variables. The main outcome was a modified Rankin Scale score of 0-2 three months after admission. Secondary outcomes were successful reperfusion and change in the National Institutes of Health Stroke Scale score after 24 h. Multivariable linear and logistic regression models were used for statistical analysis. RESULTS Functional outcomes were analyzed in 139 patients with successful reperfusion (defined as thrombolysis in cerebral infarction grade 2b-3). The mean (standard deviation) age was 76 (10.9) years, the mean (standard deviation) National Institutes of Health Stroke Scale score was 14.3 (7.5), and 70 (43.5%) patients had a left-sided vessel occlusion. Favorable functional outcome (modified Rankin Scale score 0-2) was less likely with every 10-mm Hg increase in baseline (odds ratio [OR] 0.76, P = 0.04) and pre-recanalization (OR 0.65, P = 0.011) SBP. This was also found for baseline (OR 0.76, P = 0.05) and pre-recanalization MAP (OR 0.66, P = 0.03). The maximum Youden index in a receiver operating characteristics analysis revealed an SBP of 163 mm Hg and MAP of 117 mm Hg as discriminatory thresholds during the pre-recanalization phase to predict functional outcome. CONCLUSIONS In our protocol-based setting, intraprocedural pre-recanalization BP reductions during endovascular therapy were not associated with functional outcome. However, higher intraprocedural pre-recanalization SBP and MAP were associated with worse functional outcome. Prospective randomized controlled studies are needed to determine whether BP is a feasible treatment target for the modification of outcomes.
Collapse
Affiliation(s)
- Min Chen
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Dorothea Kronsteiner
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Schieber
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Laura Jäger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Julian Bösel
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | | |
Collapse
|
41
|
Nepal G, Shrestha GS, Shing YK, Muha A, Bhagat R. Systolic blood pressure variability following endovascular thrombectomy and clinical outcome in acute ischemic stroke: A meta-analysis. Acta Neurol Scand 2021; 144:343-354. [PMID: 34110006 DOI: 10.1111/ane.13480] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/26/2021] [Accepted: 05/14/2021] [Indexed: 12/11/2022]
Abstract
Blood pressure variability (BPV) has been linked with the outcome of acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). However, the association of the stroke outcome with specific short-term BPV parameters is unclear. We did a systematic literature search for studies published from January 2010 to September 2020. Eligibility criteria included studies with (1) AIS patients treated with EVT with or without thrombolysis; and (2) analysis of the association between short-term systolic BPV parameter and clinical outcomes. Systolic BPV parameters included standard deviation (SD), coefficient of Variation (CoV), successive Variation (SV), and Variation independent of mean. A total of 11 studies were meta-analyzed, comprising 3520 patients who underwent EVT. Lower odds of achieving good functional outcome at 3 months; that is, modified Rankin Scale (mRS) score ≤2 was associated with SD (OR, 0.854; p = .02), CoV (OR, 0.572; p = .04), SV (OR 0.41; p = .00) of systolic blood pressure (SBP). Likewise, higher odds of one-point increase in mRS score was associated with SD (OR 1.42; p = .03), CoV (OR 1.464; p = .00) and SV (OR 2.605; p = .00) of SBP. However, high BPV was not associated with symptomatic intracranial hemorrhage and all-cause mortality at 90 days. The association of BPV and early neurological deterioration was inconclusive. Based on the available studies, short-term systolic BPV is indicative of the clinical outcome of patients following EVT in AIS. Further research should focus on personalized blood pressure management strategies, rather than a one-size-fits-all approach.
Collapse
Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine Tribhuvan University Institute of Medicine Kathmandu Nepal
| | | | - Yow Ka Shing
- Department of Internal Medicine National University Hospital Singapore City Singapore
| | - Allison Muha
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Riwaj Bhagat
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| |
Collapse
|
42
|
Samuels N, van de Graaf RA, van den Berg CAL, Uniken Venema SM, Bala K, van Doormaal PJ, van der Steen W, Witvoet E, Boiten J, den Hertog H, Schonewille WJ, Hofmeijer J, Schreuder F, Schreuder TAHCML, van der Worp HB, Roos YBWEM, Majoie CBLM, Burke JF, van Es ACGM, van der Lugt A, Roozenbeek B, Lingsma HF, Dippel DWJ. Blood Pressure in the First 6 Hours Following Endovascular Treatment for Ischemic Stroke Is Associated With Outcome. Stroke 2021; 52:3514-3522. [PMID: 34538090 PMCID: PMC8547588 DOI: 10.1161/strokeaha.120.033657] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Optimal blood pressure (BP) management in the acute phase of ischemic stroke remains an unresolved issue. It is uncertain whether guidelines for BP management during and after intravenous alteplase can be extrapolated to endovascular treatment (EVT) for stroke due to large artery occlusion in the anterior circulation. We evaluated the associations between systolic BP (SBP) in the first 6 hours following EVT and functional outcome as well as symptomatic intracranial hemorrhage. Methods: Patients of 8 MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry centers, with available data on SBP in the 6 hours following EVT, were analyzed. We evaluated maximum, minimum, and mean SBP. Study outcomes were functional outcome (modified Rankin Scale) at 90 days and symptomatic intracranial hemorrhage. We used multivariable ordinal and binary regression analysis to adjust for important prognostic factors and studied possible effect modification by successful reperfusion. Results: Post-EVT SBP data were available for 1161/1796 patients. Higher maximum SBP (per 10 mm Hg increments) was associated with worse functional outcome (adjusted common odds ratio, 0.93 [95% CI, 0.88–0.98]) and a higher rate of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.17 [95% CI, 1.02–1.36]). The association between minimum SBP and functional outcome was nonlinear with an inflection point at 124 mm Hg. Minimum SBP lower and higher than the inflection point were associated with worse functional outcomes (adjusted common odds ratio, 0.85 per 10 mm Hg decrements [95% CI, 0.76–0.95] and adjusted common odds ratio, 0.81 per 10 mm Hg increments [95% CI, 0.71–0.92]). No association between mean SBP and functional outcome was observed. Successful reperfusion did not modify the relation of SBP with any of the outcomes. Conclusions: Maximum SBP in the first 6 hours following EVT is positively associated with worse functional outcome and an increased risk of symptomatic intracranial hemorrhage. Both lower and higher minimum SBP are associated with worse outcomes. A randomized trial to evaluate whether modifying post-intervention SBP results in better outcomes after EVT for ischemic stroke seems justified.
Collapse
Affiliation(s)
- Noor Samuels
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Public Health (N.S., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Carlijn A L van den Berg
- Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands (S.M.U.V., H.B.v.d.W.)
| | - Kujtesa Bala
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wouter van der Steen
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Elbert Witvoet
- Department of Neurology, Haga Hospital, Den Haag, the Netherlands (E.W.)
| | - Jelis Boiten
- Department of Neurology, Haaglanden Medical Center, Den Haag, the Netherlands (J.B.)
| | - Heleen den Hertog
- Department of Neurology, Isala Hospital, Zwolle, the Netherlands (H.d.H.)
| | - Wouter J Schonewille
- Department of Neurology, Sint Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.)
| | | | - Floris Schreuder
- Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherlands (F.S.)
| | | | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands (S.M.U.V., H.B.v.d.W.)
| | - Yvo B W E M Roos
- Department of Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Centers, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine (C.B.L.M.M.), Amsterdam University Medical Centers, the Netherlands
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor (J.F.B.)
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine, Leiden University Medical Center, the Netherlands (A.C.G.M.v.E.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health (N.S., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | |
Collapse
|
43
|
Zhou T, Yi T, Li T, Zhu L, Li Y, Li Z, Wang M, Li Q, He Y, Yang P, Zhang Y, Li Z, Zhang Y, Ye X, Chen W, Wang S, Liu J. Predictors of futile recanalization in patients undergoing endovascular treatment in the DIRECT-MT trial. J Neurointerv Surg 2021; 14:752-755. [PMID: 34475255 DOI: 10.1136/neurintsurg-2021-017765] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/23/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Futile recanalization-when patients have a successful recanalization but fail to achieve a satisfactory functional outcome- is a common phenomenon of endovascular treatment of acute ischemic stroke (AIS). The present study aimed to identify the predictors of futile recanalization in AIS patients who received endovascular treatment. METHODS This is a post-hoc analysis of the DIRECT-MT trial. Demographics, clinical characteristics, acute stroke workflow interval times, biochemical parameters, and imaging characteristics were compared between futile and meaningful recanalization groups. Multivariate analysis was performed to identify the predictors of futile recanalization. RESULTS Futile recanalization was observed in 277 patients. In multivariable logistic regression analysis, older age (p<0.001), higher baseline systolic blood pressure (SBP) (p=0.032), incomplete reperfusion defined by extended Thrombolysis In Cerebral Infarction (eTICI) grades (p=0.020), and larger final infarct volume (FIV) (p<0.001) were independent predictors of futile recanalization. CONCLUSIONS Old age, high baseline SBP, incomplete reperfusion defined by eTICI, and large FIV were independent predictors of futile recanalization after endovascular therapy for AIS.
Collapse
Affiliation(s)
- Tengfei Zhou
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China.,Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China .,Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Liangfu Zhu
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yucheng Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Zhaoshuo Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Meiyun Wang
- Department of Radiology, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Qiang Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yingkun He
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Pengfei Yang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongxin Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Xiaofei Ye
- Department of Statistics, Naval Medical University, Shanghai, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Shouchun Wang
- Department of Neurology, The First Affiliated Hospital of Jilin University, Changchun, China
| | - Jianmin Liu
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | | |
Collapse
|
44
|
Chen M, Kronsteiner D, Möhlenbruch MA, Kieser M, Bendszus M, Wick W, Nagel S, Ringleb PA, Schönenberger S. Individualized blood pressure management during endovascular treatment of acute ischemic stroke under procedural sedation (INDIVIDUATE) - An explorative randomized controlled trial. Eur Stroke J 2021; 6:276-282. [PMID: 34746424 PMCID: PMC8564155 DOI: 10.1177/23969873211000879] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 02/16/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Optimal blood pressure is not well established during endovascular therapy of acute ischemic stroke. Applying standardized blood pressure target values for every stroke patient might be a suboptimal approach. AIM To assess whether an individualized intraprocedural blood pressure management with individualized blood pressure target ranges might pose a better strategy for the outcome of the patients than standardized blood pressure targets.Sample size: Randomization of 250 patients 1:1 to receive either standard or individualized blood pressure management approach. METHODS AND DESIGN We conduct an explorative single-center randomized controlled trial with a PROBE (parallel-group, open-label randomized controlled trial with blinded endpoint evaluation) design. In the control group, intraprocedural systolic blood pressure target range is 140-180 mmHg. The intervention group is the individualized approach, which is maintaining the intraprocedural systolic blood pressure at the level on presentation (±10 mmHg).Study outcomes: The primary endpoint is the modified Rankin scale assessed 90 days +/- 2 weeks after stroke onset, dichotomized by 0-2 (favorable outcome) to 3-6 (unfavorable outcome). Secondary endpoints include early neurological improvement, infarction size, and systemic physiology monitor parameters. DISCUSSION An individualized approach for blood pressure management during thrombectomy could lead to a better outcome for stroke patients. The trial is registered at clinicaltrials.gov as 'Individualized Blood Pressure Management During Endovascular Stroke Treatment (INDIVIDUATE)' under NCT04578288.
Collapse
Affiliation(s)
- Min Chen
- Department of Neurology, Heidelberg
University Hospital, Heidelberg, Germany
| | - Dorothea Kronsteiner
- Institute of Medical Biometry and
Informatics, University of Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology,
Heidelberg University Hospital, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and
Informatics, University of Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology,
Heidelberg University Hospital, Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology, Heidelberg
University Hospital, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg
University Hospital, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg
University Hospital, Heidelberg, Germany
| | | |
Collapse
|
45
|
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.
Collapse
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
| |
Collapse
|
46
|
Cai L, Rajah G, Duan H, Gao J, Cheng Z, Xin R, Jiang S, Palmer P, Geng X, Ding Y. Rapid Intravenous Glyceryl Trinitrate in Ischemic Damage (RIGID) After Stroke: Rationale, Design and Protocol for a Prospective Randomized Controlled Trial. Front Neurol 2021; 12:693330. [PMID: 34421796 PMCID: PMC8371530 DOI: 10.3389/fneur.2021.693330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Despite intravenous thrombolysis and endovascular therapy for acute ischemic stroke (AIS), many survivors still have varying degrees of disability. Glyceryl trinitrate (GTN), a nitric oxide (NO) donor, has been previously reported to induce neuroprotection after AIS. The use of GTN to reduce brain damage after stroke remains yet to be elucidated. This study was designed to explore the safety, feasibility, and preliminary efficacy of intravenous administration of GTN after AIS. Methods: A prospective randomized controlled trial is proposed with AIS patients. Participants will be randomly allocated to GTN group and control group with a 1:1 ratio (n = 40). Both groups will be treated with standard therapies according to the current stroke guidelines. Participants allocated to the GTN group will receive intravenous administration of GTN (5 mg GTN in 50 ml saline at a rate of 0.4 mg/h that is continued for 12.5 h/day for 2 days) within 24 h of symptom onset. Participants allocated to the control group will receive intravenous administration at equal capacity of 0.9% normal saline (NS) (total 50 ml/day at 4 ml/h that is continued for 12.5 h/day for 2 days). The primary outcome is safety [systolic blood pressure (SBP) <110 mmHg, headache], while the secondary outcomes include changes in functional outcome and infarction volume. Discussion: Rapid Intravenous Glyceryl Trinitrate in Ischemic Damage (RIGID) is a prospective randomized controlled trial that aims to ascertain the safety, feasibility, and preliminary efficacy of intravenous GTN as a neuroprotection strategy after AIS. These results will provide parameters for future studies as well as provide insights into treatment effects. Any possible neuroprotective qualities of GTN in AIS will also be elucidated. Trial Registration:www.chictr.org.cn, identifier: ChiCTR2100046271.
Collapse
Affiliation(s)
- Lipeng Cai
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Gary Rajah
- Department of Neurosurgery, Munson Medical Center, Traverse City, MI, United States
| | - Honglian Duan
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jie Gao
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zhe Cheng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Ruiqiang Xin
- Department of Medical Imaging, Luhe Hospital, Capital Medical University, Beijing, China
| | - Shangqian Jiang
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Peter Palmer
- Department of Neurology, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
| |
Collapse
|
47
|
van de Graaf RA, Samuels N, Chalos V, Lycklama A Nijeholt GJ, van Beusekom H, Yoo AJ, van Zwam WH, Majoie CBLM, Roos YBWEM, van Doormaal PJ, Ben Hassen W, van der Lugt A, Dippel DWJ, Lingsma HF, van Es ACGM, Roozenbeek B. Predictors of poor outcome despite successful endovascular treatment for ischemic stroke: results from the MR CLEAN Registry. J Neurointerv Surg 2021; 14:660-665. [PMID: 34266905 DOI: 10.1136/neurintsurg-2021-017726] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Approximately one-third of patients with ischemic stroke treated with endovascular treatment do not recover to functional independence despite rapid and successful recanalization. We aimed to quantify the importance of predictors of poor functional outcome despite successful reperfusion. METHODS We analyzed patients from the MR CLEAN Registry between March 2014 and November 2017 with successful reperfusion (extended Thrombolysis In Cerebral Infarction ≥2B). First, predictors were selected based on expert opinion and were clustered according to acquisition over time (ie, baseline patient factors, imaging factors, treatment factors, and postprocedural factors). Second, several models were constructed to predict 90-day functional outcome (modified Rankin Scale (mRS)). The relative importance of individual predictors in the most extensive model was expressed by the proportion of unique added χ2 to the model of that individual predictor. RESULTS Of 3180 patients, 1913 (60%) had successful reperfusion. Of these 1913 patients, 1046 (55%) were functionally dependent at 90 days (mRS >2). The most important predictors for mRS were baseline patient factors (ie, pre-stroke mRS, added χ2 0.16; National Institutes of Health Stroke Scale score at baseline, added χ2 0.12; age, added χ2 0.10), and postprocedural factors (ie, symptomatic intracranial hemorrhage (sICH), added χ2 0.12; pneumonia, added χ2 0.09). The probability of functional independence for a typical stroke patient with sICH was 54% (95% CI 36% to 72%) lower compared with no sICH, and 21% (95% CI 4% to 38%) for pneumonia compared with no pneumonia. CONCLUSION Baseline patient factors and postprocedural adverse events are important predictors of poor functional outcome in successfully reperfused patients with ischemic stroke. This implies that prevention of postprocedural adverse events has the greatest potential to further improve outcomes in these patients.
Collapse
Affiliation(s)
- Rob A van de Graaf
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands .,Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Noor Samuels
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Vicky Chalos
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Heleen van Beusekom
- Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Wim H van Zwam
- Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Pieter Jan van Doormaal
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Wagih Ben Hassen
- Interventional Neuroradiology, Saint Anne Hospital Centre, Paris, Île-de-France, France
| | - Aad van der Lugt
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | - Hester F Lingsma
- Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Adriaan C G M van Es
- Radiology and Nuclear Medicine, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Bob Roozenbeek
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | |
Collapse
|
48
|
Li Z, Zhang H, Han J, Chu Z, Zhao S, Yang Q, Huang X, Zhou Z. Time Course and Clinical Relevance of Neurological Deterioration After Endovascular Recanalization Therapy for Anterior Circulation Large Vessel Occlusion Stroke. Front Aging Neurosci 2021; 13:651614. [PMID: 34267642 PMCID: PMC8277420 DOI: 10.3389/fnagi.2021.651614] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/04/2021] [Indexed: 11/23/2022] Open
Abstract
Neurological deterioration (ND) is a devastating complication for patients with ischemic stroke after endovascular recanalization therapy (EVT). We aimed to investigate the time course and clinical relevance of ND after EVT. Consecutive patients with acute ischemic stroke who underwent EVT for large arterial occlusions of the anterior cerebral circulation were enrolled. The National Institutes of Health Stroke Scale (NIHSS) scores were assessed before EVT, at the end of EVT, at 24 h (d1), on day 3 (d3), on day 15 (d15), at discharge and anytime when ND was indicated. ND was defined as an increase of ≥ 4 points in the NIHSS score and was divided into acute ND (AD, within 24 h), subacute ND (SD, d1–d3), and delayed ND (DD, d3–d15 or discharge). Using multivariable logistic regression analysis, we explored predictors and outcomes of ND at different time periods. As a result, of 343 patients, 129 (37.6%) experienced ND, including 90 (26.2%) with AD, 27 (7.9%) with SD and 12 (3.5%) with DD. Multivariable logistic regression analysis revealed that history of hypertension, cardioembolic stroke, lower Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and poor collaterals were significantly associated with an increased risk of AD; history of hypertension, lower ASPECTS, poor collaterals, and unsuccessful recanalization, with SD; and high admission NIHSS score, with DD. In addition, patients who experienced AD (OR = 10.22, P < 0.001), SD (OR = 15.89, P = 0.004), or DD (OR = 8.31, P = 0.015) were more likely to have poor outcomes. ND was a strong predictor of poor stroke outcomes. Management of related risk factors at different ND time periods might improve the prognosis of EVT.
Collapse
Affiliation(s)
- Zibao Li
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Hongchuan Zhang
- Department of Radiology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Jian Han
- Department of Neurology, Huangshan City People's Hospital, Huangshan, China
| | - Zhaohu Chu
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Shoucai Zhao
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Qian Yang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| |
Collapse
|
49
|
Collette SL, Uyttenboogaart M, Samuels N, van der Schaaf IC, van der Worp HB, Luijckx GJR, Venema AM, Sahinovic MM, Dierckx RAJO, Lingsma HF, Kappen TH, Bokkers RPH. Hypotension during endovascular treatment under general anesthesia for acute ischemic stroke. PLoS One 2021; 16:e0249093. [PMID: 34161331 PMCID: PMC8221480 DOI: 10.1371/journal.pone.0249093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/10/2021] [Indexed: 12/03/2022] Open
Abstract
Objective The effect of anesthetic management (general anesthesia [GA], conscious sedation, or local anesthesia) on functional outcome and the role of blood pressure management during endovascular treatment (EVT) for acute ischemic stroke is under debate. We aimed to determine whether hypotension during EVT under GA is associated with functional outcome at 90 days. Methods We retrospectively collected data from patients with a proximal intracranial occlusion of the anterior circulation treated with EVT under GA. The primary outcome was the distribution on the modified Rankin Scale at 90 days. Hypotension was defined using two thresholds: a mean arterial pressure (MAP) of 70 mm Hg and a MAP 30% below baseline MAP. To quantify the extent and duration of hypotension, the area under the threshold (AUT) was calculated using both thresholds. Results Of the 366 patients included, procedural hypotension was observed in approximately half of them. The occurrence of hypotension was associated with poor functional outcome (MAP <70 mm Hg: adjusted common odds ratio [acOR], 0.57; 95% confidence interval [CI], 0.35–0.94; MAP decrease ≥30%: acOR, 0.76; 95% CI, 0.48–1.21). In addition, an association was found between the number of hypotensive periods and poor functional outcome (MAP <70 mm Hg: acOR, 0.85 per period increase; 95% CI, 0.73–0.99; MAP decrease ≥30%: acOR, 0.90 per period; 95% CI, 0.78–1.04). No association existed between AUT and functional outcome (MAP <70 mm Hg: acOR, 1.000 per 10 mm Hg*min increase; 95% CI, 0.998–1.001; MAP decrease ≥30%: acOR, 1.000 per 10 mm Hg*min; 95% CI, 0.999–1.000). Conclusions Occurrence of procedural hypotension and an increase in number of procedural hypotensive periods were associated with poor functional outcome, whereas the extent and duration of hypotension were not. Randomized clinical trials are needed to confirm our hypothesis that hypotension during EVT under GA has detrimental effects.
Collapse
Affiliation(s)
- Sabine L. Collette
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- * E-mail:
| | - Maarten Uyttenboogaart
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Noor Samuels
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert Jan R. Luijckx
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Allart M. Venema
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marko M. Sahinovic
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rudi A. J. O. Dierckx
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Teus H. Kappen
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | |
Collapse
|
50
|
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.
Collapse
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
| |
Collapse
|