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Leslie-Mazwi TM. Neurocritical Care for Patients With Ischemic Stroke. Continuum (Minneap Minn) 2024; 30:611-640. [PMID: 38830065 DOI: 10.1212/con.0000000000001427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Management of stroke due to large vessel occlusion (LVO) has undergone unprecedented change in the past decade. Effective treatment with thrombectomy has galvanized the field and led to advancements in all aspects of care. This article provides a comprehensive examination of neurologic intensive care unit (ICU) management of patients with stroke due to LVO. The role of the neurocritical care team in stroke systems of care and the importance of prompt diagnosis, initiation of treatment, and continued monitoring of patients with stroke due to LVO is highlighted. LATEST DEVELOPMENTS The management of complications commonly associated with stroke due to LVO, including malignant cerebral edema and respiratory failure, are addressed, stressing the importance of early identification and aggressive treatment in mitigating negative effects on patients' prognoses. In the realm of medical management, this article discusses various medical therapies, including antithrombotic therapy, blood pressure management, and glucose control, outlining evidence-based strategies for optimizing patient outcomes. It further emphasizes the importance of a multidisciplinary approach to provide a comprehensive care model. Lastly, the critical aspect of family communication and prognostication in the neurologic ICU is addressed. ESSENTIAL POINTS This article emphasizes the multidimensional aspects of neurocritical care in treating patients with stroke due to LVO.
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Liao Z, Tian L, Wen M, Wang B, Ding K, Song Q. Safety and Efficacy of Intensive Blood Pressure-Lowering After Successful Endovascular Therapy in AIS: A Meta-Analysis. Neurologist 2024:00127893-990000000-00133. [PMID: 38767590 DOI: 10.1097/nrl.0000000000000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
OBJECTIVES Higher blood pressure has been proven to be associated with poorer functional outcomes after successful reperfusion by EVT. However, the effect of intensive blood pressure-lowering regimens in these patients remains controversial and ambiguous in clinical practice. We propose further analysis aimed at determining the effect of an intensive blood pressure-lowering regimen after EVT in AIS. METHODS The protocol registered in PROSPERO CRD42023360989. We performed a systematic search that was comprehensively executed in online databases for studies published up to June 2022. Eligibility criteria were established based on the PICOS model. The Cochrane risk of bias algorithm was used to evaluate the risk of bias. The effect models were applied to calculate the pooled ORs and CIs via Review Manager 5.4 software. RESULTS A total of 1582 citations were identified, 3 randomized clinical trials and 2 retrospective cohort studies were included. Data from 3211 patients were analyzed. We revealed that intensive blood pressure-lowering interventions could significantly reduce symptomatic intraparenchymal hemorrhage compared with standard blood pressure lowering. Nevertheless, favorable functional outcome, poor outcome, all-cause mortality within 3 months and intraparenchymal hemorrhage in 24 hours showed no significant differences. Subgroup analysis revealed the variability of systolic blood pressure within 24 hours after EVT was not associated with odds of poor outcome and intraparenchymal hemorrhage. CONCLUSIONS Based on the current evidence, intensive blood pressure-lowering regimen was superior to standard blood pressure-lowering regimen for a reduced risk of symptomatic intraparenchymal hemorrhage in AIS patients treated with EVT, but there was no statistically significant difference found between the 2 regimens for the other outcomes.
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Affiliation(s)
- Zhouzan Liao
- Department of Neurology, Youxian People's Hospital, Zhuzhou
| | - Li Tian
- Functional Department, Hunan University of Medicine General Hospital, Huaihua
| | - Ming Wen
- Department of Neurology, Youxian People's Hospital, Zhuzhou
| | - Bing Wang
- Department of Neurology, Youxian People's Hospital, Zhuzhou
| | - Kai Ding
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Guilin Medical University, Guilin
- Department of Geriatrics, Hunan University of Medicine General Hospital, Huaihua, China
| | - Qionglin Song
- Functional Department, Hunan University of Medicine General Hospital, Huaihua
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Li J, Liu BJ, Wang YJ, Cui Y, Chen HS. Antihypertensive Drugs Affect the Association of Systolic Blood Pressure Variability with Outcomes in Patients with Acute Stroke who had Successful Recanalization after Endovascular Treatment. J Atheroscler Thromb 2024; 31:616-625. [PMID: 38220185 PMCID: PMC11079479 DOI: 10.5551/jat.64637] [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: 09/25/2023] [Accepted: 11/05/2023] [Indexed: 01/16/2024] Open
Abstract
AIMS Blood pressure variability (BPV) was associated with the clinical outcomes in patients with acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) after endovascular treatment (EVT). This study aimed to investigate whether the use of antihypertensive drugs could affect this association in patients with AIS-LVO after EVT. METHODS We retrospectively screened consecutive patients with AIS-LVO who had successful recanalization after EVT and calculated their systolic BPV (SBPV) during the first 24 h after EVT using eight statistical methodologies based on previously published literature. Poor outcome was defined as a modified Rankin Scale score of 3-6 at 90 days. Logistic regression analysis was performed to assess this association, and different prediction models were constructed to assess the effect of the use of antihypertensive drugs. RESULTS A total of 214 patients were finally included, including 92 (43.0%) with good outcomes, and 136 (63.6%) who received antihypertensive drugs. SBPV indicators were significantly lower in patients with good outcomes versus those with poor outcomes. The logistic analysis showed that all SBPV indicators were consistently associated with poor outcomes (odds ratio, 1.031-1.282, all P<0.05) in all populations, which was confirmed in patients not using antihypertensive drugs. However, no SBPV indicator was found to be associated with poor outcomes in patients using antihypertensive drugs. Receiver operating characteristic curves showed that the area under the curve (AUC) was larger in the model adjusting for antihypertensive drugs (AUC 0.774-0.783) compared with the one not adjusted for antihypertensive drugs (AUC 0.739-0.754). CONCLUSION In the anterior circulation of patients with AIS-LVO who had successful recanalization after EVT, the utilization of antihypertensive drugs may have some impact on the relationship between SBPV and clinical outcomes.
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Affiliation(s)
- Jing Li
- Department of Neurology, General Hospital of Northern Theater Command; Shenyang, China
| | - Bai-Jun Liu
- Department of Neurology, General Hospital of Northern Theater Command; Shenyang, China
| | - Ying-Jia Wang
- Department of Neurology, General Hospital of Northern Theater Command; Shenyang, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command; Shenyang, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command; Shenyang, China
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Liu J, Gu Y, Zhang DZ. Cerebral circulation time on DSA after thrombectomy associated with hemorrhagic transformation in acute ischemic stroke. Acta Neurochir (Wien) 2024; 166:64. [PMID: 38315216 DOI: 10.1007/s00701-024-05959-6] [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: 10/11/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND To investigate the association between cerebral circulation time (CCT) on digital subtraction angiography immediately after thrombectomy and hemorrhagic transformation (HT) in acute ischemic stroke (AIS). METHODS Retrospectively enrolled consecutive AIS patients presented with large vessel occlusion who received thrombectomy and achieved successful recanalization between January 2019 and June 2021. The time interval from the beginning of the siphon segment of internal carotid artery visualization until the end of the arterial phase during cerebral angiography was calculated as CCT. The independent association of CCT with HT was evaluated using logistic regression analyses. The receiver operating characteristic curve was analyzed to evaluate the association between CCT and HT. RESULTS Two hundred and twenty-four patients were included, of whom 86 (38.4%) suffered HT. Compared with patients without HT, patients with HT were of advanced age, less commonly male, had more diabetes mellitus, had higher baseline National Institutes of Health Stroke Scale score, lower Alberta Stroke Program Early Computed Tomographic Score, and shorter CCT (P < 0.05). Multivariable logistic regression suggested that CCT was independently associated with HT (adjusted odds ratio, 0.170; 95% confidence interval, 0.004-0.450; P < 0.001). According to the receiver operating characteristic curve, the optimal cut-off value for the strong correlation between CCT and HT was 1.72 s, which had 76.6% sensitivity, 81.6% specificity, and the area under the curve was 0.846. CONCLUSION Shorter post-thrombectomy CCT was independently associated with HT.
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Affiliation(s)
- Jianyu Liu
- Department of Interventional Radiology, Jiangsu Taizhou People's Hospital, Hailing District, Taizhou, Jiangsu, China
| | - Yuanyuan Gu
- Department of Emergency Medicine, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China
| | - Da-Zhong Zhang
- Department of Interventional Radiology, Jiangsu Taizhou People's Hospital, Hailing District, Taizhou, Jiangsu, China.
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Sheriff FG, Ahmad A, Inam ME, Khatri R, Maud A, Rodriguez GJ. A systematic review on the assessment of cerebral autoregulation in patients with Large Vessel Occlusion. Front Neurol 2023; 14:1287873. [PMID: 38046584 PMCID: PMC10693431 DOI: 10.3389/fneur.2023.1287873] [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: 09/02/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
As the majority of large vessel occlusion (LVO) patients are not treated with revascularization therapies or efficiently revascularized, complementary management strategies are needed. In this article we explore the importance of cerebral autoregulation (CA) assessment in the prediction and/or modification of infarct growth and hemorrhagic transformation. In patients with LVO, these are important factors that affect prognosis. A systematic search of the PubMed, EMBASE databases and a targeted Google search was conducted, resulting in the inclusion of 34 relevant articles. There is an agreement that CA is impaired in patients with LVO; several factors have been identified such as time course, revascularization status, laterality, disease subtype and location, some of which may be potentially modifiable and affect outcomes. The personalized CA assessment of these patients suggests potential for better understanding of the inter-individual variability. Further research is needed for the development of more accurate, noninvasive techniques for continuous monitoring and personalized thresholds for CA.
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Affiliation(s)
- Faheem G. Sheriff
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | | | - Mehmet E. Inam
- University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rakesh Khatri
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Alberto Maud
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Gustavo J. Rodriguez
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
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Zaki HA, Lloyd SA, Elmoheen A, Bashir K, Elsayed WAE, Abdelrahim MG, Basharat K, Azad A. Antihypertensive Interventions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis Evaluating Clinical Outcomes Through an Emergency Medicine Paradigm. Cureus 2023; 15:e47729. [PMID: 38021612 PMCID: PMC10676241 DOI: 10.7759/cureus.47729] [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] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
High blood pressure (HBP) is usually prominent after the onset of acute ischemic stroke (AIS). Although previous studies have found that about half of patients with AIS have a background of hypertension, there is no clear etiology for HBP in AIS. The literature reveals discrepancies in the relationship between HBP and clinical outcomes of AIS, pointing toward the contested effect of blood pressure (BP) reduction clinical outcomes. Thus, the potential benefits and hazards of HBP treatment were explored in the context of clinical outcomes after AIS. An electronic database and a manual search were carried out to identify all the articles related to this topic and published between 2000 and January 2023. The Review Manager software was also used to perform the meta-analysis and quality appraisal. In analyses related to patients not treated with reperfusion therapies, mortality, and dependency outcomes were categorized as short-term (<3 months) or long-term (≥3 months). Our search strategy yielded 2459 articles, of which only 15 met the inclusion criteria. The results of our meta-analysis demonstrate that in patients not treated with reperfusion therapies, BP lowering had no significant impact on either short-term or long-term mortality (risk ratio (RR): 1.18; 95% confidence interval (CI): 0.81-1.73; p = 0.39, and RR: 1.04; 95% CI: 0.77-1.40; p = 0.81, respectively) and dependency (RR: 1.12; 95% CI: 0.97-1.30; p = 0.11, and RR: 0.98; 95% CI: 0.90-1.07; p = 0.61, respectively). Furthermore, BP lowering prior to reperfusion showed no significant effect on mortality (RR: 0.7; 95% CI: 0.23-2.26; p = 0.58), but it did significantly reduce the risk of dependency (RR: 0.89; 95% CI: 0.85-0.94; p < 0.00001). When the dataset was restricted to patients who had successful reperfusion, intensive BP lowering (target systolic BP <120 mmHg) was found to increase the risk of dependency (RR: 1.23; 95% CI: 1.09-1.39; p = 0.0009). In addition, BP reduction had an insignificant effect on the risk of recurrent strokes and combined vascular events (RR: 1.00; 95% CI: 0.54-1.84; p = 1.00, and RR: 0.99; 95% CI: 0.70-1.41; p = 0.95, respectively). Lowering BP in patients not treated with reperfusion therapies is not beneficial in reducing the risk of either short or long-term mortality and dependency. However, BPR before reperfusion reduces the risk of dependency, while aggressive BPR (target systolic blood pressure (SBP) <120 mmHg) after successful reperfusion increases the risk of dependency. Therefore, we recommend BPR as early as possible for patients undergoing reperfusion therapies but suggest against aggressive BPR in patients who have undergone successful reperfusion.
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Affiliation(s)
- Hany A Zaki
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
| | | | - Amr Elmoheen
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
| | - Khalid Bashir
- Medicine, Qatar University, Doha, QAT
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
| | | | | | | | - Aftab Azad
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
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Kim BJ, Singh N, Kim H, Menon BK, Almekhlafi M, Ryu WS, Kim JT, Kang J, Baik SH, Kim JY, Lee KJ, Jung C, Han MK, Bae HJ. Association between blood pressure and endovascular treatment outcomes differs by baseline perfusion and reperfusion status. Sci Rep 2023; 13:13776. [PMID: 37612355 PMCID: PMC10447432 DOI: 10.1038/s41598-023-40572-0] [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: 10/26/2022] [Accepted: 08/13/2023] [Indexed: 08/25/2023] Open
Abstract
We hypothesized that the association between BP and endovascular treatment (EVT) outcomes would differ by baseline perfusion and recanalization status. We identified 388 ICA or M1 occlusion patients who underwent EVT ≤ 24 h from onset with successful recanalization (TICI ≥ 2b). BP was measured at 5-min intervals from arrival and during the procedure. Systolic BPs (SBP) were summarized as dropmax (the maximal decrease over two consecutive measurements), incmax (the maximal increase), mean, coefficient of variation (cv), and standard deviation. Adequate baseline perfusion was defined as hypoperfusion intensity ratio (HIR) ≤ 0.5; infarct proportion as the volume ratio of final infarcts within the Tmax > 6 s region. In the adequate perfusion group, infarct proportion was closely associated with SBPdropmax (β ± SE (P-value); 1.22 ± 0.48, (< 0.01)), SBPincmax (1.12 ± 0.33, (< 0.01)), SBPcv (0.61 ± 0.15 (< 0.01)), SBPsd (0.66 ± 0.08 (< 0.01)), and SBPmean (0.71 ± 0.37 (0.053) before recanalization. The associations remained significant only in SBPdropmax, SBPincmax, and SBPmean after recanalization. SBPincmax, SBPcv and SBPsd showed significant associations with modified Rankin Scale score at 3 months in the pre-recanalization period. In the poor perfusion group, none of the SBP indices was associated with any stroke outcomes regardless of recanalization status. BP may show differential associations with stroke outcomes by the recanalization and baseline perfusion status.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea.
- Cerebrovascular Center, Gyeonggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea.
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea.
| | - Nishita Singh
- Neurology division, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Hyeran Kim
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Bijoy K Menon
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Mohammed Almekhlafi
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Cerebrovascular Center, Gyeonggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jun Yup Kim
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Cerebrovascular Center, Gyeonggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Keon-Joo Lee
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Cerebrovascular Center, Gyeonggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Office #8710, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Cerebrovascular Center, Gyeonggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
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Raha O, Hall C, Malik A, D'Anna L, Lobotesis K, Kwan J, Banerjee S. Advances in mechanical thrombectomy for acute ischaemic stroke. BMJ MEDICINE 2023; 2:e000407. [PMID: 37577026 PMCID: PMC10414072 DOI: 10.1136/bmjmed-2022-000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/25/2023] [Indexed: 08/15/2023]
Abstract
Mechanical thrombectomy is a ground breaking treatment for acute ischaemic stroke caused by occlusion of a large vessel. Its efficacy over intravenous thrombolysis has been proven in multiple trials with a lower number needed to treat than percutaneous coronary intervention for acute myocardial infarction. However, access to this key treatment modality remains limited with a considerable postcode lottery across the UK and many parts of the world. The evidence base for mechanical thrombectomy dates back to 2015. Since then, there have been important advances in establishing and widening the criteria for treatment. This narrative review aims to summarise the current evidence base and latest advances for physicians and academics with an interest in recanalisation treatments for acute ischaemic stroke.
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Affiliation(s)
- Oishik Raha
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Charles Hall
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
| | - Abid Malik
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Lucio D'Anna
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Joseph Kwan
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Soma Banerjee
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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Zhou J, Samara H, Ebrahim A, Kinariwala J, Mohamed W. Blood pressure variability and short-term outcomes after mechanical thrombectomy in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107197. [PMID: 37267795 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107197] [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: 11/22/2022] [Revised: 05/13/2023] [Accepted: 05/19/2023] [Indexed: 06/04/2023] Open
Abstract
OBJECTIVES There is limited data evaluating effects of post-mechanical thrombectomy (MT) blood pressure (BP) control on short-term clinical outcomes in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). We aim to investigate the association of BP variations, after MT, with stroke early outcomes. MATERIALS AND METHODS A retrospective study was conducted on AIS patients with LVO undergoing MT at a tertiary center over 3.5 years. Hourly BP data was recorded within the first 24- and 48-hours post-MT. BP variability was expressed as the interquartile range (IQR) of BP distribution. Short-term favorable outcome was defined as modified Rankin scale (mRS) 0-3, discharge to home or inpatient rehabilitation facility (IRF). RESULTS Of the 95 enrolled subjects, 37(38.9%) had favorable outcomes at discharge and 8 (8.4%) died. After adjustment for confounders, an increase in IQR of systolic blood pressure (SBP) within the first 24 hours after MT revealed a significant inverse association with favorable outcomes (OR 0.43, 95% CI [0.19, 0.96], p = 0.039). Increased median MAP within the first 24 hours after MT correlated with favorable outcomes (OR 1.75, 95% CI [1.09, 2.83], p = 0.021). Subgroup analysis redemonstrated significant inverse association between increased SBP IQR and favorable outcomes (OR 0.48, 95% CI [0.21, 0.97], p = 0.042) among patients with successful revascularization. CONCLUSIONS Post-MT high SBP variability was associated with worse short-term outcomes in AIS patients with LVO regardless of recanalization status. MAP values may be used as indicators for functional prognosis.
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Affiliation(s)
- Jiping Zhou
- Department of Neurology, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Heba Samara
- Department of Neurology, Kymera Independent Physicians, Roswell, NM, USA
| | - Ali Ebrahim
- Department of Neurology, Golden Valley Memorial Healthcare, Clinton, MO, USA
| | - Jay Kinariwala
- Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Wazim Mohamed
- Department of Neurology, Wayne State University/Detroit Medical Center, Detroit, MI, USA.
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Chen C, Ouyang M, Ong S, Zhang L, Zhang G, Delcourt C, Mair G, Liu L, Billot L, Li Q, Chen X, Parsons M, Broderick JP, Demchuk AM, Bath PM, Donnan GA, Levi C, Chalmers J, Lindley RI, Martins SO, Pontes-Neto OM, Venturelli PM, Olavarría V, Lavados P, Robinson TG, Wardlaw JM, Li G, Wang X, Song L, Anderson CS. Effects of intensive blood pressure lowering on cerebral ischaemia in thrombolysed patients: insights from the ENCHANTED trial. EClinicalMedicine 2023; 57:101849. [PMID: 36820100 PMCID: PMC9938155 DOI: 10.1016/j.eclinm.2023.101849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 02/17/2023] Open
Abstract
Background Intensive blood pressure lowering may adversely affect evolving cerebral ischaemia. We aimed to determine whether intensive blood pressure lowering altered the size of cerebral infarction in the 2196 patients who participated in the Enhanced Control of Hypertension and Thrombolysis Stroke Study, an international randomised controlled trial of intensive (systolic target 130-140 mm Hg within 1 h; maintained for 72 h) or guideline-recommended (systolic target <180 mm Hg) blood pressure management in patients with hypertension (systolic blood pressure >150 mm Hg) after thrombolysis treatment for acute ischaemic stroke between March 3, 2012 and April 30, 2018. Methods All available brain imaging were analysed centrally by expert readers. Log-linear regression was used to determine the effects of intensive blood pressure lowering on the size of cerebral infarction, with adjustment for potential confounders. The primary analysis pertained to follow-up computerised tomography (CT) scans done between 24 and 36 h. Sensitivity analysis were undertaken in patients with only a follow-up magnetic resonance imaging (MRI) and either MRI or CT at 24-36 h, and in patients with any brain imaging done at any time during follow-up. This trial is registered with ClinicalTrials.gov, number NCT01422616. Findings There were 1477 (67.3%) patients (mean age 67.7 [12.1] y; male 60%, Asian 65%) with available follow-up brain imaging for analysis, including 635 patients with a CT done at 24-36 h. Mean achieved systolic blood pressures over 1-24 h were 141 mm Hg and 149 mm Hg in the intensive group and guideline group, respectively. There was no effect of intensive blood pressure lowering on the median size (ml) of cerebral infarction on follow-up CT at 24-36 h (0.3 [IQR 0.0-16.6] in the intensive group and 0.9 [0.0-12.5] in the guideline group; log Δmean -0.17, 95% CI -0.78 to 0.43). The results were consistent in sensitivity and subgroup analyses. Interpretation Intensive blood pressure lowering treatment to a systolic target <140 mm Hg within several hours after the onset of symptoms may not increase the size of cerebral infarction in patients who receive thrombolysis treatment for acute ischaemic stroke of mild to moderate neurological severity. Funding National Health and Medical Research Council of Australia; UK Stroke Association; UK Dementia Research Institute; Ministry of Health and the National Council for Scientific and Technological Development of Brazil; Ministry for Health, Welfare, and Family Affairs of South Korea; Takeda.
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Affiliation(s)
- Chen Chen
- Neurology Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Menglu Ouyang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Sheila Ong
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Luyun Zhang
- The George Institute for Global Health China, Beijing, China
- Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, Shenyang, China
| | - Guobin Zhang
- The George Institute for Global Health China, Beijing, China
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Grant Mair
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences and Centre in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Leibo Liu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Xiaoying Chen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Mark Parsons
- Ingham Institute for Applied Medical Research, Liverpool Hospital, UNSW, Sydney, Australia
| | - Joseph P. Broderick
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Andrew M. Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Geoffrey A. Donnan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Christopher Levi
- Neurology Department, John Hunter Hospital, and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Richard I. Lindley
- University of Sydney, Sydney, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Sheila O. Martins
- Stroke Division of Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Octavio M. Pontes-Neto
- Stroke Service - Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of Sao Paulo, Ribeirão Preto, SP, Brazil
| | - Paula Muñoz Venturelli
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Centro de Estudios Clínicos, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Verónica Olavarría
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Pablo Lavados
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Thompson G. Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences and Centre in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Gang Li
- Neurology Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xia Wang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lili Song
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Craig S. Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
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Nie X, Leng X, Miao Z, Fisher M, Liu L. Clinically Ineffective Reperfusion After Endovascular Therapy in Acute Ischemic Stroke. Stroke 2023; 54:873-881. [PMID: 36475464 DOI: 10.1161/strokeaha.122.038466] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endovascular treatment is a highly effective therapy for acute ischemic stroke due to large vessel occlusion. However, in clinical practice, nearly half of the patients do not have favorable outcomes despite successful recanalization of the occluded artery. This unfavorable outcome can be defined as having clinically ineffective reperfusion. The objective of the review is to describe clinically ineffective reperfusion after endovascular therapy and its underlying risk factors and mechanisms, including initial tissue damage, cerebral edema, the no-reflow phenomenon, reperfusion injury, procedural features, and variations in postprocedural management. Further research is needed to more accurately identify patients at a high risk of clinically ineffective reperfusion after endovascular therapy and to improve individualized periprocedural management strategies, to increase the chance of achieving favorable clinical outcomes.
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Affiliation(s)
- Ximing Nie
- Department of Neurology (X.N., L.L.), Beijing Tiantan Hospital, Capital Medical University, China.,China National Clinical Research Center for Neurological Diseases, Beijing (X.N., L.L.)
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, SAR (X.L.)
| | - Zhongrong Miao
- Department of Interventional Neuroradiology (Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Liping Liu
- Department of Neurology (X.N., L.L.), Beijing Tiantan Hospital, Capital Medical University, China.,China National Clinical Research Center for Neurological Diseases, Beijing (X.N., L.L.)
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12
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Kim BJ, Menon BK, Yoo J, Han JH, Kim BJ, Kim CK, Kim JG, Kim JT, Park H, Baik SH, Han MK, Kang J, Kim JY, Lee KJ, Park JM, Kang K, Lee SJ, Cha JK, Kim DH, Jeong JH, Park TH, Park SS, Lee KB, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi KH, Choi JC, Kim JG, Kwon JH, Kim WJ, Shin DI, Yum KS, Sohn SI, Hong JH, Kim C, Lee SH, Lee J, Almekhlafi MA, Demchuk A, Bae HJ. Effectiveness and safety of EVT in patients with acute LVO and low NIHSS. Front Neurol 2022; 13:955725. [PMID: 35989920 PMCID: PMC9389111 DOI: 10.3389/fneur.2022.955725] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purposeThere is much uncertainty in endovascular treatment (EVT) decisions in patients with acute large vessel occlusion (LVO) and mild neurological deficits.MethodsFrom a prospective, nationwide stroke registry, all patients with LVO and baseline NIHSS <6 presenting within 24 h from the time last known well (LKW) were included. Early neurological deterioration (END) developed before EVT was prospectively collected as an increasing total NIHSS score ≥2 or any worsening of the NIHSS consciousness or motor subscores during hospitalization not related to EVT. Significant hemorrhage was defined as PH2 hemorrhagic transformation or hemorrhage at a remote site. The modified Rankin Scale (mRS) was prospectively collected at 3 months.ResultsAmong 1,083 patients, 149 (14%) patients received EVT after a median of 5.9 [3.6–12.3] h after LKW. In propensity score-matched analyses, EVT was not associated with mRS 0-1 (matched OR 0.99 [0.63–1.54]) but increased the risk of a significant hemorrhage (matched OR, 4.51 [1.59–12.80]). Extraneous END occurred in 207 (19%) patients after a median of 24.5 h [IQR, 13.5–41.9 h] after LKW (incidence rate, 1.41 [95% CI, 1.23–1.62] per 100 person-hours). END unrelated to EVT showed a tendency to modify the effectiveness of EVT (P-for-interaction, 0.08), which decreased the odds of having mRS 0–1 in mild LVO patients without END (adjusted OR, 0.63 [0.40–0.99]).ConclusionsThe use of EVT in patients with acute LVO and low NIHSS scores may require the assessment of individual risks of early deterioration, hemorrhagic complications and expected benefit.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- *Correspondence: Beom Joon Kim
| | - Bijoy K. Menon
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yongin-si, South Korea
| | - Jung Hoon Han
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jihoon Kang
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Keon-Joo Lee
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu-si, South Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, South Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Jin-Heon Jeong
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, South Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, South Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Joong-Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University Hospital, Ulsan, South Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, Ulsan, South Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si, South Korea
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Chulho Kim
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si, South Korea
| | - Sang-Hwa Lee
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si, South Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University, Seoul, South Korea
| | - Mohammed A. Almekhlafi
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Andrew Demchuk
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
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Robichon E, Maïer B, Mazighi M. Endovascular therapy for acute ischemic stroke: The importance of blood pressure control, sedation modality and anti-thrombotic management to improve functional outcomes. Rev Neurol (Paris) 2022; 178:175-184. [DOI: 10.1016/j.neurol.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 08/08/2021] [Accepted: 09/27/2021] [Indexed: 01/04/2023]
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Woodhouse LJ, Appleton JP, Scutt P, Everton L, Wilkinson G, Caso V, Czlonkowska A, Gommans J, Krishnan K, Laska AC, Ntaios G, Ozturk S, Phillips S, Pocock S, Prasad K, Szatmari S, Wardlaw JM, Sprigg N, Bath PM. Effect of continuing versus stopping pre-stroke antihypertensive agents within 12 h on outcome after stroke: A subgroup analysis of the efficacy of nitric oxide in stroke (ENOS) trial. EClinicalMedicine 2022; 44:101274. [PMID: 35112073 PMCID: PMC8790472 DOI: 10.1016/j.eclinm.2022.101274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 12/20/2021] [Accepted: 01/07/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND It is not known whether to continue or temporarily stop existing antihypertensive drugs in patients with acute stroke. METHODS We performed a prospective subgroup analysis of patients enrolled into the Efficacy of Nitric Oxide in Stroke (ENOS) trial who were randomised to continue vs stop prior antihypertensive therapy within 12 h of stroke onset. The primary outcome was functional outcome, assessed with the modified Rankin Scale at 90 days by observers blinded to treatment assignment, and analysed with ordinal logistic regression. FINDINGS Of 4011 patients recruited into ENOS from 2001 to 2014, 2097 patients were randomised to continue vs stop prior antihypertensive treatment, and 384 (18.3%, continue 185, stop 199) were enrolled within 12 h of ictus: mean (SD) age 71.8 (11.8) years, female 193 (50.3%), ischaemic stroke 342 (89.1%) and total anterior circulation syndrome 114 (29.7%). As compared with stopping, continuing treatment within 12 h of onset lowered blood pressure by 15.5/9.6 mmHg (p<0.001/<0.001) by 7 days, shifted the modified Rankin Scale to a worse outcome by day 90, adjusted common odds ratio (OR) 1.46 (95% CI 1.01-2.11), and was associated with an increased death rate by day 90 (hazard ratio 2.17, 95% CI 1.24-3.79). Other outcomes (disability - Barthel Index, quality of life - EQ-visual analogue scale, cognition - telephone mini-mental state examination, and mood - Zung depression scale) were also worse with continuing treatment. INTERPRETATION In this pre-specified subgroup analysis of the large ENOS trial, continuing prior antihypertensive therapy within 12 h of stroke onset in a predominantly ischaemic stroke population was unsafe with worse functional outcome, disability, cognition, mood, quality of life and increased death. Future studies assessing continuing or stopping prior antihypertensives in the context of thrombectomy are awaited.
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Affiliation(s)
- Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
| | - Jason P. Appleton
- Stroke, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2GW, UK
- Institute of Applied Health Research, College of Dental and Medical Sciences, University of Birmingham, Birmingham, UK
| | - Polly Scutt
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
| | - Lisa Everton
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - Gwenllian Wilkinson
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Italy
| | | | - John Gommans
- Department of Medicine, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - Ann C. Laska
- Department of Clinical Science, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Greece
| | - Serefnur Ozturk
- Neurology, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Stephen Phillips
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Kameshwar Prasad
- Rajendra Institute of Medical Sciences, Ranchi, Jharkhand 834009, India
| | - Szabolcs Szatmari
- Department of Neurology, Clinical County Emergency Hospital, Targu Mures, Romania
| | - Joanna M. Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
- Corresponding author at: Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK.
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Lee E, Song YJ, Jeon S, Lee J, Lee E, Lee JY, Lee E, Han MK, Jeong HG. Risk Factors for Intravenous Propacetamol-Induced Blood Pressure Drop in the Neurointensive Care Unit: A Retrospective Observational Study. Neurocrit Care 2021; 36:888-896. [PMID: 34791593 DOI: 10.1007/s12028-021-01390-2] [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: 07/17/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Intravenous propacetamol is commonly used to control fever and pain in neurocritically ill patients in whom oral administration is often difficult. However, several studies reported that intravenous propacetamol may cause blood pressure drop. Thus, we aimed to investigate the occurrence and risk factors for intravenous propacetamol-induced blood pressure drop in neurocritically ill patients. METHODS This retrospective study included consecutive patients who were administered intravenous propacetamol in a neurointensive care unit at a single tertiary academic hospital between April 2013 and June 2020. The exact timing of intravenous propacetamol administration was collected from a database of the electronic barcode medication administration system. Blood pressure drop was defined as a systolic blood pressure below 90 mm Hg or a decrease by 30 mm Hg or more. Blood pressure, pulse rate, and body temperature were collected at baseline and within 2 h after intravenous propacetamol administration. The incidence of blood pressure drop was evaluated, and multivariable logistic regression analysis was performed to identify risk factors for blood pressure drop events. RESULTS A total of 16,586 instances of intravenous propacetamol administration in 4916 patients were eligible for this study. Intravenous propacetamol resulted in a significant decrease in systolic blood pressure (baseline 131.1 ± 17.8 mm Hg; within 1 h 124.6 ± 17.3 mm Hg; between 1 and 2 h 123.4 ± 17.4 mm Hg; P < 0.01). The incidence of blood pressure drop events was 13.5% within 2 h after intravenous propacetamol. Older age, lower or higher baseline systolic blood pressure, fever, higher Acute Physiology and Chronic Health Evaluation II score, and concomitant administration of vasopressors/inotropes or analgesics/sedatives were significant factors associated with the occurrence of blood pressure drop events after intravenous propacetamol administration. CONCLUSIONS Intravenous propacetamol can induce hemodynamic changes and blood pressure drop events in neurocritically ill patients. This study identified the risk factors for blood pressure drop events. On the basis of our results, judicious use of intravenous propacetamol is warranted for neurocritically ill patients with risk factors that make them more susceptible to hemodynamic changes.
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Affiliation(s)
- Eunah Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Young Joo Song
- Department of Pharmacy, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Sujeong Jeon
- Department of Pharmacy, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Junghwa Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Eunsook Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea
| | - Euni Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, 08826, Republic of Korea
| | - Han-Gil Jeong
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, 08826, Republic of Korea. .,Division of Neurocritical Care, Department of Neurosurgery and Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
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16
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Artery diameter ratio after recanalization in endovascular therapy for acute ischemic stroke: a new predictor of clinical outcomes. Neuroradiology 2021; 64:785-793. [PMID: 34708259 DOI: 10.1007/s00234-021-02841-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/18/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study aimed to investigate the relationship between the artery diameter ratio (ADR) after recanalization and clinical outcomes. METHODS Patients with middle cerebral artery occlusion confirmed by DSA from 1 January 2018, to 31 December 2019, were retrospectively analyzed. All patients confirmed TICI grade 2b or 3. The ADR was calculated as M2 segment diameter/M1 segment diameter. Multivariate regression analysis was used to describe clinical outcomes of two groups (ADR < 0.6 and ≥ 0.6). ROC curves were used to compare different models and find the best cutoff. RESULTS A total of 143 patients were included in the study, including 77 males and 66 females, with an average age of 67.79 ± 12 years. The NIHSS at discharge was significantly higher in the ADR < 0.6 group than another group (mean, 16.37 vs. 6.19, P < 0.001). At 90 days, the cases of functional independence was significantly less in the ADR < 0.6 group (20.97% vs. 83.95%, OR 0.05, 95% CI 0.02-0.12, P < 0.001). The ADR < 0.6 group had a higher incidence of cerebral edema (P = 0.027) and sICH (P = 0.038). The ADR had the strongest power to distinguish mRS > 2 (AUC = 0.851) and DC (AUC = 0.805), and the best cutoff value are 0.6 (specificity 85.19%, sensitivity 75.81%) and 0.58 (specificity 65.96%, sensitivity 100%), respectively. CONCLUSION The low ADR is associated with poor outcomes. The decrease in ADR may be an indirect manifestation of the loss of cerebrovascular autoregulation.
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Kim BJ, Singh N, Menon BK. Hemodynamics of Leptomeningeal Collaterals after Large Vessel Occlusion and Blood Pressure Management with Endovascular Treatment. J Stroke 2021; 23:343-357. [PMID: 34649379 PMCID: PMC8521259 DOI: 10.5853/jos.2021.02446] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 12/14/2022] Open
Abstract
Endovascular therapy (EVT) is an effective treatment for ischemic stroke due to large vessel occlusion (LVO). Unlike intravenous thrombolysis, EVT enables visualization of the restoration of blood flow, also known as successful reperfusion in real time. However, until successful reperfusion is achieved, the survival of the ischemic brain is mainly dependent on blood flow from the leptomeningeal collaterals (LMC). It plays a critical role in maintaining tissue perfusion after LVO via pre-existing channels between the arborizing pial small arteries or arterioles overlying the cerebral hemispheres. In the ischemic territory where the physiologic cerebral autoregulation is impaired and the pial arteries are maximally dilated within their capacity, the direction and amount of LMC perfusion rely on the systemic perfusion, which can be estimated by measuring blood pressure (BP). After the EVT procedure, treatment focuses on mitigating the risk of hemorrhagic transformation, potentially via BP reduction. Thus, BP management may be a key component of acute care for patients with LVO stroke. However, the guidelines on BP management during and after EVT are limited, mostly due to the scarcity of high-level evidence on this issue. In this review, we aim to summarize the anatomical and physiological characteristics of LMC to maintain cerebral perfusion after acute LVO, along with a landscape summary of the literature on BP management in endovascular treatment. The objective of this review is to describe the mechanistic association between systemic BP and collateral perfusion after LVO and thus provide clinical and research perspectives on this topic.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Nishita Singh
- Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Bijoy K. Menon
- Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
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Low Hypoperfusion Intensity Ratio Is Associated with a Favorable Outcome Even in Large Ischemic Core and Delayed Recanalization Time. J Clin Med 2021; 10:jcm10091869. [PMID: 33925888 PMCID: PMC8123392 DOI: 10.3390/jcm10091869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/17/2022] Open
Abstract
In ischemic brain tissue, hypoperfusion severity can be assessed using the hypoperfusion intensity ratio (HIR). We evaluated the link between HIR and clinical outcomes after successful recanalization by endovascular treatment. We retrospectively reviewed 162 consecutive patients who underwent endovascular treatment for intracranial large vessel occlusion. The HIR was calculated using an automated software program, with initial computed tomography perfusion images. The HIR was compared between patients with and without favorable outcomes. To observe the modifying effect of the HIR on the well-known major outcome determinants, regression analyses were performed in the low and high HIR groups. The median HIR value was significantly lower in patients with a favorable outcome, with an optimal cut-off point of 0.54. The HIR was an independent factor for a favorable outcome in a specific multivariable model and was significantly correlated with the Alberta Stroke Program Early Computed Tomography Score (ASPECTS). In contrast to the high HIR group, the low HIR group showed that ASPECTS and onset-to-recanalization time were not independently associated with a favorable outcome. Finally, the low HIR group had a more favorable outcome even in cases with an unfavorable ASPECTS and onset-to-recanalization time. The HIR could be useful in predicting outcomes after successful recanalization.
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Shin DW, Gorelick PB, Bae HJ. Time-dependent shift of the relationship between systolic blood pressure and clinical outcome in acute lacunar stroke. Int J Stroke 2021; 17:400-406. [PMID: 33724096 DOI: 10.1177/17474930211006243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS This study explores the relationship between systolic blood pressure during the acute period of stroke and poor functional outcome in patients with lacunar stroke, emphasizing a possible time-dependent nature of the relationship. METHODS Based on multicenter stroke registry data, patients with acute lacunar stroke were identified, and systolic blood pressure levels at eight time points (1, 2, 4, 8, 16, 24, 48, and 72 h) after stroke onset were extracted at the 15 participating centers in South Korea. Poor functional outcome was defined as a three-month modified Rankin Scale score of 2-6. Non-linear restricted cubic spline and linear models were used for assessing the relationship at each time point. RESULTS A total of 97,349 systolic blood pressure measurements of 3,042 patients were analyzed. At 1 h and 4 h after stroke onset, the relationship between systolic blood pressure and poor outcome showed a non-linear association. The nadir was 155 mmHg at 1 h and 124 mmHg at 4 h. After this time period, a higher systolic blood pressure was associated with a poorer outcome. This linear relationship weakened over time after 12 h (coefficient values of the adjusted linear models: 0.0081 at 8 h, 0.0105 at 12 h, 0.0102 at 24 h, 0.0082 at 48 h, 0.0054 at 72 h). CONCLUSIONS Based on our cohort of large number of lacunar stroke patients, our findings suggest that systolic blood pressure levels may follow a time-dependent course in relation to prediction of outcome at three months. The findings may be valuable for hypothesis generation in association with clinical trial development for blood pressure control in acute stroke patients.
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Affiliation(s)
- Dong W Shin
- Department of Neurology and Cerebrovascular Center, 65462Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Philip B Gorelick
- Davee Department of Neurology, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, 65462Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
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20
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Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke (BP-TARGET): a multicentre, open-label, randomised controlled trial. Lancet Neurol 2021; 20:265-274. [DOI: 10.1016/s1474-4422(20)30483-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 01/10/2023]
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21
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Cantone M, Lanza G, Puglisi V, Vinciguerra L, Mandelli J, Fisicaro F, Pennisi M, Bella R, Ciurleo R, Bramanti A. Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021; 11:70. [PMID: 33430236 PMCID: PMC7825668 DOI: 10.3390/brainsci11010070] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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Affiliation(s)
- Mariagiovanna Cantone
- Department of Neurology, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy
- Department of Neurology IC, Oasi Research Institute—IRCCS, Via Conte Ruggero, 73, 94018 Troina, Italy
| | - Valentina Puglisi
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Jaime Mandelli
- Department of Neurosurgery, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Manuela Pennisi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy;
| | - Rosella Ciurleo
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
| | - Alessia Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
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22
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Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021. [PMID: 33430236 DOI: 10.3390/brainsci11010070.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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23
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Maïer B, Delvoye F, Labreuche J, Escalard S, Desilles JP, Redjem H, Hébert S, Smajda S, Ciccio G, Lapergue B, Blanc R, Piotin M, Mazighi M. Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review. Front Neurol 2020; 11:573382. [PMID: 33193021 PMCID: PMC7659685 DOI: 10.3389/fneur.2020.573382] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: Optimal blood pressure (BP) targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) still need to be assessed, especially according to the recanalization status. Facing the lack of randomized controlled trials addressing this question, we performed a systematic review of studies assessing the post-EVT BP impact on functional outcome and symptomatic intracranial hemorrhage (sICH). Methods: Studies published after January 1, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work. Results: Five studies were included in the present analysis. Despite a significant heterogeneity among studies which precluded a meta-analysis, systolic BP (SBP) was the most frequently used parameter to describe BP. BP variability (standard deviation, successive variability) after EVT was associated with worse functional outcome, especially in studies without specific BP targets after successful EVT. Lower BP values after successful EVT were associated with lower odds of sICH. Four studies evaluated the post-EVT BP impact on recanalized patients solely, with only one specifically addressing the impact of a TICI 2B vs. 2C. Interestingly, SBP reduction was inversely associated with worse outcomes in TICI 3 patients but not in TICI 2B patients, pointing to the potential value of BP management according to the exact TICI. Conclusions: BP post-EVT seems to be associated with worse functional outcomes and sICH. However, given the important heterogeneity depicted among the included studies, no decisive conclusion can be made from this systematic review, thus underlying the urgent need of randomized controlled trials evaluating this question.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
- Université de Paris, Paris, France
| | - François Delvoye
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Julien Labreuche
- University Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Simon Escalard
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Hocine Redjem
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Solène Hébert
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Stanislas Smajda
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Gabriele Ciccio
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | | | - Raphaël Blanc
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
- FHU Neurovasc, Paris, France
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24
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Thrombectomy for acute ischemic stroke patients with isolated distal internal carotid artery occlusion: a retrospective observational study. Neuroradiology 2020; 63:777-786. [PMID: 33029734 PMCID: PMC8041676 DOI: 10.1007/s00234-020-02550-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/06/2020] [Indexed: 11/19/2022]
Abstract
Purpose Acute stroke patients presenting with a distal internal carotid artery occlusion and patent carotid terminus, allowing for collateral flow via the circle of Willis, may have a more favorable natural history. Therefore, benefit of endovascular treatment (EVT) is less evident. We performed an exploratory analysis of EVT results compared to conservative treatment in patients with ‘carotid-I’ occlusions. Methods We report on EVT-treated and non-EVT-treated patients with carotid-I occlusions from the MR CLEAN Registry, MR CLEAN trial, and our comprehensive stroke center. CT-angiography was reviewed on primary collateral patency and choroid plexus enhancement. Perfusion deficits were assessed on CT-perfusion (CTP). Clot migration was assessed by comparing clot location on baseline CTA to its location on periprocedural digital subtraction angiography. Outcomes included 90-day functional independence (mRS 0–2), successful reperfusion and mortality. Results We included 51 patients. Forty-one patients received EVT, ten patients did not. Intravenous thrombolysis was administered in 32 (78%) EVT-treated patients and 6 (60%) non-EVT-treated patients. CTP, available for 17 patients, showed hypoperfusion on cerebral blood flow maps in 13 (76%) patients. Successful reperfusion after EVT occurred in 23 (56%), and clot migration in 8 patients (20%). Functional independence was achieved in 54% (21/39) of EVT-treated and in 10% (1/10) of non-EVT-treated patients. Mortality was 26% (10/39) and 30% (3/10), respectively. Anterior choroidal artery patency and choroid plexus enhancement were positively associated with functional independence. Conclusion In our population, data suggest improved outcomes after EVT in carotid-I occlusion patients and provide no arguments to withhold EVT in these patients. Electronic supplementary material The online version of this article (10.1007/s00234-020-02550-5) contains supplementary material, which is available to authorized users.
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25
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Das S, John KD, Bokka SK, Remmel K, Akça O. Blood Pressure Management Following Large Vessel Occlusion Strokes: A Narrative Review. Balkan Med J 2020; 37:253-259. [PMID: 32475092 PMCID: PMC7424178 DOI: 10.4274/balkanmedj.galenos.2020.2020.4.196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Stroke is one of the leading causes of morbidity and mortality worldwide. Intravenous tissue plasminogen activator and mechanical thrombectomy comprise the two major treatments for acute ischemic stroke. Tissue plasminogen activator has been used for more than two decades and guidelines for hemodynamic management following tissue plasminogen activator administration are well established. However, mechanical thrombectomy is a relatively newer therapy and there is a paucity of evidence regarding hemodynamic management following large vessel occlusion strokes. The important tenets guiding the pathophysiology of large vessel occlusion strokes include understanding of cerebral autoregulation, collateral circulation, and blood pressure variability. In this narrative review, we discuss the current American Heart Association-American Stroke Association guidelines for the early management of acute ischemic stroke during different phases of the illness, encountered at different sections of a hospital including the emergency room, the neuro-interventional suite, and the intensive care unit. There is emerging evidence with regard to post-recanalization blood pressure management following large vessel occlusion strokes. Future research directions will include rea-ltime blood pressure variability assessments, identifying the extent of impaired autoregulation, and providing guidelines related to range and personalized blood pressure trajectories for patients following large vessel occlusion strokes.
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Affiliation(s)
- Saurav Das
- Department of Neurology, Louisville University School of Medicine, Louisville, Kentucky, USA
| | - Kevin Denny John
- University of Louisville, School of Medicine, Louisville, Kentucky, USA
| | - Satheesh Kumar Bokka
- Department of Neurology, Louisville University School of Medicine, Louisville, Kentucky, USA
| | - Kerri Remmel
- Department of Anesthesiology and Perioperative Medicine, Stroke ICU, Louisville University Hospital, Louisville, Kentucky, USA
- Comprehensive Stroke Clinical Research Program, University of Louisville, Louisville, Kentucky, USA
| | - Ozan Akça
- Department of Anesthesiology and Perioperative Medicine, Stroke ICU, Louisville University Hospital, Louisville, Kentucky, USA
- Comprehensive Stroke Clinical Research Program, University of Louisville, Louisville, Kentucky, USA
- * Address for Correspondence: Comprehensive Stroke Clinical Research Program, University of Louisville, Louisville, Kentucky, USA Phone: +90 502 852 58 51 E-mail:
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26
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Effect of blood pressure on early neurological deterioration of acute ischemic stroke patients with intravenous rt-PA thrombolysis may be mediated through oxidative stress induced blood-brain barrier disruption and AQP4 upregulation. J Stroke Cerebrovasc Dis 2020; 29:104997. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 04/18/2020] [Accepted: 05/23/2020] [Indexed: 02/08/2023] Open
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27
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Malhotra K, Goyal N, Katsanos AH, Filippatou A, Mistry EA, Khatri P, Anadani M, Spiotta AM, Sandset EC, Sarraj A, Magoufis G, Krogias C, Tönges L, Safouris A, Elijovich L, Goyal M, Arthur A, Alexandrov AV, Tsivgoulis G. Association of Blood Pressure With Outcomes in Acute Stroke Thrombectomy. Hypertension 2020; 75:730-739. [PMID: 31928111 DOI: 10.1161/hypertensionaha.119.14230] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Limited data exist evaluating the effect of blood pressure (BP) on clinical outcomes among patients with acute ischemic stroke with large vessel occlusion treated with mechanical thrombectomy (MT). We sought to evaluate the association of BP levels on clinical outcomes among patients with acute ischemic stroke with large vessel occlusion treated with MT. Studies were identified that reported the association of systolic BP (SBP) or diastolic BP levels before, during, or after MT on the outcomes of patients with acute ischemic stroke treated with MT. Unadjusted and adjusted analyses of studies reporting odds ratios (ORadj) per 10 mm Hg BP increment were performed. Our analysis included 25 studies comprising 6474 patients. Higher pre-MT mean SBP (P=0.008) and post-MT maximum SBP (P=0.009) levels were observed in patients who died within 3 months. Patients with 3-month functional independence were noted to have lower pre-MT (P<0.001) and post-MT maximum SBP levels (P<0.001). In adjusted analyses, increasing post-MT maximum SBP and diastolic BP levels were associated with 3-month mortality (ORadj, 1.19 [95% CI,1.00-1.43]; I2=78%, P value for Cochran Q test: 0.001) and symptomatic intracranial hemorrhage (ORadj, 1.65 [95% CI, 1.11-2.44]; I2=0%, P value for Cochran Q test: 0.80), respectively. Increasing pre- and post-MT mean SBP levels were associated with lower odds of 3-month functional independence (ORadj, 0.86 [95% CI, 0.77-0.96]; I2=18%, P value for Cochran Q test: 0.30) and (ORadj, 0.80 [95% CI, 0.72-0.89]; I2=0%, P value for Cochran Q test: 0.51), respectively. In conclusion, elevated BP levels before and after MT are associated with adverse outcomes among patients with acute ischemic stroke with large vessel occlusion.
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Affiliation(s)
- Konark Malhotra
- From the Department of Neurology, Allegheny Health Network, Pittsburgh, PA (K.M.)
| | - Nitin Goyal
- Department of Neurology, University of Tennessee, Memphis (N.G., A.V.A., G.T.)
| | - Aristeidis H Katsanos
- Department of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K.)
| | - Angeliki Filippatou
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Greece (A.F., G.T.)
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University, Nashville, TN (E.A.M.)
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, OH (P.K.)
| | - Mohammad Anadani
- Department of Neurology, Washington University School of Medicine, St Louis, MO (M.A.).,Department of Neurosurgery, Medical University of South Carolina, Charleston (M.A., A.M.S.)
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston (M.A., A.M.S.)
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Norway (E.C.S.).,The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S.)
| | - Amrou Sarraj
- Department of Neurology, UT Houston, TX (A. Sarraj)
| | - Georgios Magoufis
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M., A. Safouris)
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany (C.K., L.T.)
| | - Lars Tönges
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany (C.K., L.T.)
| | | | - Lucas Elijovich
- Department of Neurosurgery, University of Tennessee/Semmes-Murphey Clinic, Memphis (L.E., A.A.)
| | - Mayank Goyal
- Departments of Radiology and Clinical Neurosciences, University of Calgary, AB, Canada (M.G.)
| | - Adam Arthur
- Department of Neurosurgery, University of Tennessee/Semmes-Murphey Clinic, Memphis (L.E., A.A.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee, Memphis (N.G., A.V.A., G.T.)
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee, Memphis (N.G., A.V.A., G.T.).,Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Greece (A.F., G.T.)
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