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Xu D, Qi P, Liu P, Yang H, Ye G, Shan D, Lei S, Yang G, Ding J, Liang H, Qi H, Wang D, Lu J. Machine learning models reveal the critical role of nighttime systolic blood pressure in predicting functional outcome for acute ischemic stroke after endovascular thrombectomy. Front Neurol 2024; 15:1405668. [PMID: 38784914 PMCID: PMC11112097 DOI: 10.3389/fneur.2024.1405668] [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: 03/23/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
Background Blood pressure (BP) is a key factor for the clinical outcomes of acute ischemic stroke (AIS) receiving endovascular thrombectomy (EVT). However, the effect of the circadian pattern of BP on functional outcome is unclear. Methods This multicenter, retrospective, observational study was conducted from 2016 to 2023 at three hospitals in China (ChiCTR2300077202). A total of 407 patients who underwent endovascular thrombectomy (EVT) and continuous 24-h BP monitoring were included. Two hundred forty-one cases from Beijing Hospital were allocated to the development group, while 166 cases from Peking University Shenzhen Hospital and Hainan General Hospital were used for external validation. Postoperative systolic BP (SBP) included daytime SBP, nighttime SBP, and 24-h average SBP. Least absolute shrinkage and selection operator (LASSO), support vector machine-recursive feature elimination (SVM-RFE), Boruta were used to screen for potential features associated with functional dependence defined as 3-month modified Rankin scale (mRS) score ≥ 3. Nine algorithms were applied for model construction and evaluated using area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy. Results Three hundred twenty-eight of 407 (80.6%) patients achieved successful recanalization and 182 patients (44.7%) were functional independent. NIHSS at onset, modified cerebral infarction thrombolysis grade, atrial fibrillation, coronary atherosclerotic heart disease, hypertension were identified as prognostic factors by the intersection of three algorithms to construct the baseline model. Compared to daytime SBP and 24-h SBP models, the AUC of baseline + nighttime SBP showed the highest AUC in all algorithms. The XGboost model performed the best among all the algorithms. ROC results showed an AUC of 0.841 in the development set and an AUC of 0.752 in the validation set for the baseline plus nighttime SBP model, with a brier score of 0.198. Conclusion This study firstly explored the association between circadian BP patterns with functional outcome for AIS. Nighttime SBP may provide more clinical information regarding the prognosis of patients with AIS after EVT.
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Affiliation(s)
- Dingkang Xu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Peng Qi
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Peng Liu
- Department of Neurosurgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Hongchun Yang
- Department of Neurosurgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Gengfan Ye
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo University, Ningbo, Zhejiang, China
| | - Dezhi Shan
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Shixiong Lei
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Guozheng Yang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Junqing Ding
- Neurology Department, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hui Liang
- Department of Neurology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Hainan Province Clinical, Medical Center and Hainan Academician Innovation Platform, Haikou, China
| | - Hui Qi
- Department of Neurosurgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Daming Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Jun Lu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
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Zhang Z, Pu Y, Yu L, Bai H, Duan W, Liu X, Nie X, Wen Z, Zheng L, Hu X, Leng X, Pan Y, Petersen NH, Liu L. Deviation From Personalized Blood Pressure Targets Correlates With Worse Outcome After Successful Recanalization. J Am Heart Assoc 2024; 13:e033633. [PMID: 38533955 PMCID: PMC11179781 DOI: 10.1161/jaha.123.033633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/28/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Personalized blood pressure (BP) management for patients with acute ischemic stroke after successful endovascular thrombectomy lacks evidence. We aimed to investigate whether the deviation of BP from cerebral autoregulation limits is associated with worse outcomes. METHODS AND RESULTS We determined autoregulation by measuring mean velocity index and calculated the percentage of time and the burden (defined as the time-BP area) with BP outside the autoregulatory limits of each subject within 48 hours after endovascular thrombectomy. In total, 91 patients with large vessel occlusion stroke who had achieved successful recanalization were prospectively enrolled between May 2020 and February 2022. The burden with BP outside the autoregulatory limits was associated with poor outcome (modified Rankin Scale score 3-6) at 90 days (adjusted odds ratio, 1.28 [95% CI, 1.03-1.59]). The percentage of time with BP out of the autoregulatory limits was correlated with early neurological deterioration (National Institute of Health Stroke Scale scores increased ≥2 at 7 days) (adjusted odds ratio, 1.38 [95% CI, 1.04-1.83]). The burden of BP that decreased below the autoregulatory lower limit was associated with significant infarct growth (volume of infarct growth >11.6 mL) at 7 days (adjusted odds ratio, 1.21 [95% CI, 1.01-1.44]). The percentage of time that BP exceeded the autoregulatory upper limit was associated with symptomatic intracranial hemorrhage within 48 hours (adjusted odds ratio, 1.55 [95% CI, 1.02-2.34]). CONCLUSIONS Both the percentage of time and the burden of BP that deviates from the autoregulation-preserved range are associated with unfavorable clinical outcomes. This study highlights the potential benefits of autoregulation-guided BP management strategy after successful recanalization.
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Affiliation(s)
- Zhe Zhang
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- Center for Data Science, Nell Hodgson Woodruff School of NursingEmory UniversityAtlantaGA
| | - Yuehua Pu
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Lei Yu
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- Department of Neurology, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Haiwei Bai
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- Department of NeurologyThe Forth Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wanying Duan
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Xin Liu
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Ximing Nie
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Zhixuan Wen
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Lina Zheng
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- Division of Neurology, Department of Medicine & TherapeuticsChinese University of Hong Kong, Prince of Wales HospitalShatinHong Kong SAR
| | - Xiao Hu
- Center for Data Science, Nell Hodgson Woodruff School of NursingEmory UniversityAtlantaGA
| | - Xinyi Leng
- Division of Neurology, Department of Medicine & TherapeuticsChinese University of Hong Kong, Prince of Wales HospitalShatinHong Kong SAR
| | - Yuesong Pan
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan HospitalBeijingChina
| | - Nils H. Petersen
- Divisions of Neurocritical Care and Stroke, Department of NeurologyYale New Haven Hospital, Yale School of MedicineNew HavenCT
| | - Liping Liu
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan HospitalBeijingChina
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3
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Wang H, Guo Y, Xu J, Sun Y, Ji Y, Xu X, Yang Q, Huang X, Zhou Z. Blood pressure variability and outcome in atherosclerosis versus cardioembolism cerebral large vessel occlusion after successful thrombectomy. Hypertens Res 2024; 47:898-909. [PMID: 37978233 DOI: 10.1038/s41440-023-01500-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
Higher blood pressure variability (BPV) has been proven associated with worse functional outcome after endovascular treatment (EVT). However, this association is not established according to different stroke etiologies. In this study, we compared patients with the two highest proportions of stroke etiologies-cardioembolism (CE) and large-artery atherosclerosis (LAA), aiming to explore appropriate strategies of BP management for different etiologies. We enrolled patients with large vessel occlusion (LVO) in anterior circulation who underwent EVT and achieved successful recanalization retrospectively. 24-h blood pressure (BP) and BPV measured as blood pressure reduction (BPr), standard deviation (SD), coefficient of variation (CV), successive variation (SV), average real variability (ARV) after EVT were collected for systolic blood pressure (SBP) and diastolic blood pressure (DBP). The favorable outcome was defined as functional independence by 90-day modified Rankin Scale (mRS 0-2). In our cohort, higher BPV parameters significantly resulted in 90d functional dependence in CE-LVO patients (SBPSV OR: 1.083, 95%CI = 1.009-1.163; SBPARV OR: 1.121, 95%CI = 1.019-1.233; DBPSD OR: 1.124, 95%CI = 1.007-1.1256; DBPCV OR: 1.078, 95%CI = 1.002-1.161). However, for LAA-LVO patients, no positive results correlated 90d functional dependence with 24-hour BPV. Additionally, 90d functional dependence in CE patients with poor collaterals were significantly dependent on post-procedural BPV (DBPmax OR: 1.044, 95%CI = 1.002-1.087; DBPSD OR: 1.229, 95%CI = 1.022-1.1.479; DBPCV OR: 1.143, 95%CI = 1.009-1.295). Whereas to patients with good collaterals, there did not exist such a correlation. In summary, stroke etiologies should probably be taken into consideration to optimize individualized BP management strategies. In order to achieve better clinical outcomes for patients with acute ischemic stroke due to large vessel occlusion, stricter blood pressure management should be taken in cardioembolic stroke patients in contrast with large artery atherosclerotic stroke patients after successful endovascular therapy.
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Affiliation(s)
- Hao Wang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yapeng Guo
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Junfeng Xu
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yi Sun
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yachen Ji
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xiangjun Xu
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Qian Yang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xianjun Huang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China.
| | - Zhiming Zhou
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China.
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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.
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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
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5
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Abuelazm M, Khildj Y, Ibrahim AA, Mahmoud A, Amin AM, Gowaily I, Khan U, Abdelazeem B, Brašić JR. Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischemic Stroke: a Systematic Review and Meta-Analysis. Clin Neuroradiol 2024:10.1007/s00062-024-01391-6. [PMID: 38453701 DOI: 10.1007/s00062-024-01391-6] [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: 11/25/2023] [Accepted: 01/22/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE Optimal clinical outcome with successful recanalization from endovascular thrombectomy (EVT) requires optimal blood pressure (BP) management. We aimed to evaluate the efficacy and safety of the intensive BP target (< 140 mm Hg) versus the standard BP target (< 180 mm Hg) after EVT for acute ischemic stroke. METHODS We conducted a systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) obtained from PubMed, Embase Cochrane, Scopus, and WOS until September 7th, 2023. We used the fixed-effect model to report dichotomous outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD), with a 95% confidence interval (CI). PROSPERO ID CRD42023463206. RESULTS We included four RCTs with 1559 patients. There was no difference between intensive BP and standard BP targets regarding the National Institutes of Health Stroke Scale (NIHSS) change after 24 h [MD: 0.44 with 95% CI (0.0, 0.87), P = 0.05]. However, the intensive BP target was significantly associated with a decreased risk of excellent neurological recovery (mRS ≤ 1) [RR: 0.87 with 95% CI (0.76, 0.99), P = 0.03], functional independence (mRS ≤ 2) [RR: 0.81 with 95% CI (0.73, 0.90), P = 0.0001] and independent ambulation (mRS ≤ 3) [RR: 0.85 with 95% CI (0.79, 0.92), P < 0.0001]. CONCLUSIONS An intensive BP target after EVT is associated with worse neurological recovery and significantly decreased rates of functional independence and independent ambulation compared to the standard BP target. Therefore, the intensive BP target should be avoided after EVT for acute ischemic stroke.
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Affiliation(s)
| | - Yehya Khildj
- Faculty of Medicine, University of Algiers, Algiers, Algeria
| | | | | | | | | | - Ubaid Khan
- Faculty of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, West Virginia, USA
| | - James Robert Brašić
- Section of High-Resolution Brain Positron Emission Tomography Imaging, Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Behavioral Health, New York City Health and Hospitals/Bellevue, New York, NY, USA
- Department of Psychiatry, New York University Grossman School of Medicine, New York University Langone Health, New York, NY, USA
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6
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Katsanos AH, Joundi RA, Palaiodimou L, Ahmed N, Kim JT, Goyal N, Maier IL, de Havenon A, Anadani M, Matusevicius M, Mistry EA, Khatri P, Arthur AS, Sarraj A, Yaghi S, Shoamanesh A, Catanese L, Psychogios MN, Tsioufis K, Malhotra K, Spiotta AM, Sandset EC, Alexandrov AV, Petersen NH, Tsivgoulis G. Blood Pressure Trajectories and Outcomes After Endovascular Thrombectomy for Acute Ischemic Stroke. Hypertension 2024; 81:629-635. [PMID: 38164751 DOI: 10.1161/hypertensionaha.123.22164] [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: 10/03/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Data on systolic blood pressure (SBP) trajectories in the first 24 hours after endovascular thrombectomy (EVT) in acute ischemic stroke are limited. We sought to identify these trajectories and their relationship to outcomes. METHODS We combined individual-level data from 5 studies of patients with acute ischemic stroke who underwent EVT and had individual blood pressure values after the end of the procedure. We used group-based trajectory analysis to identify the number and shape of SBP trajectories post-EVT. We used mixed effects regression models to identify associations between trajectory groups and outcomes adjusting for potential confounders and reported the respective adjusted odds ratios (aORs) and common odds ratios. RESULTS There were 2640 total patients with acute ischemic stroke included in the analysis. The most parsimonious model identified 4 distinct SBP trajectories, that is, general directional patterns after repeated SBP measurements: high, moderate-high, moderate, and low. Patients in the higher blood pressure trajectory groups were older, had a higher prevalence of vascular risk factors, presented with more severe stroke syndromes, and were less likely to achieve successful recanalization after the EVT. In the adjusted analyses, only patients in the high-SBP trajectory were found to have significantly higher odds of early neurological deterioration (aOR, 1.84 [95% CI, 1.20-2.82]), intracranial hemorrhage (aOR, 1.84 [95% CI, 1.31-2.59]), mortality (aOR, 1.75 [95% CI, 1.21-2.53), death or disability (aOR, 1.63 [95% CI, 1.15-2.31]), and worse functional outcomes (adjusted common odds ratio,1.92 [95% CI, 1.47-2.50]). CONCLUSIONS Patients follow distinct SBP trajectories in the first 24 hours after an EVT. Persistently elevated SBP after the procedure is associated with unfavorable short-term and long-term outcomes.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., R.A.J., A.S., L.C.)
| | - Raed A Joundi
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., R.A.J., A.S., L.C.)
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon University Hospital, School of Medicine (L.P., G.T.), National and Kapodistrian University of Athens, Greece
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., M.M.)
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (N.A., M.M.)
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea (J.-T.K.)
| | - Nitin Goyal
- Department of Neurology (N.G., G.T., A.V.A.), University of Tennessee Health Science Center, Memphis
- Department of Neurosurgery (N.G., A.S.A.), University of Tennessee Health Science Center, Memphis
| | - Ilko L Maier
- Department of Neurology, University Medical Center Goettingen, Germany (I.L.M.)
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City (A.d.H.)
| | - Mohammad Anadani
- Department of Neurology, (M.A.), Medical University of South Carolina, Charleston
- Department of Neurosurgery (MA., A.M.S.), Medical University of South Carolina, Charleston
| | - Marius Matusevicius
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., M.M.)
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (N.A., M.M.)
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee (E.A.M.)
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Ohio (P.K.)
| | - Adam S Arthur
- Department of Neurosurgery (N.G., A.S.A.), University of Tennessee Health Science Center, Memphis
| | - Amrou Sarraj
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., R.A.J., A.S., L.C.)
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY (S.Y.)
| | - Ashkan Shoamanesh
- Department of Neurology, Case Western Reserve University, University Hospitals Cleveland Medical Center, OH (A.S.)
| | - Luciana Catanese
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., R.A.J., A.S., L.C.)
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland (M.-N.P.)
| | - Konstantinos Tsioufis
- First Department of Cardiology, Hippokration Hospital (K.T.), National and Kapodistrian University of Athens, Greece
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania (K.M.)
| | - Alejandro M Spiotta
- Department of Neurosurgery (MA., A.M.S.), Medical University of South Carolina, Charleston
| | | | - Andrei V Alexandrov
- Department of Neurology (N.G., G.T., A.V.A.), University of Tennessee Health Science Center, Memphis
| | - Nils H Petersen
- Department of Neurology, Yale University, New Haven (N.H.P.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine (L.P., G.T.), National and Kapodistrian University of Athens, Greece
- Department of Neurology (N.G., G.T., A.V.A.), University of Tennessee Health Science Center, Memphis
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7
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Wu MN, Liu YP, Fong YO, Lin YH, Yang IH, Chou PS, Hsu CY, Lin HF. The impact of blood pressure variability on the development of parenchymal hematoma in acute cerebral infarction with atrial fibrillation. Hypertens Res 2024; 47:618-627. [PMID: 37872378 DOI: 10.1038/s41440-023-01479-5] [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: 06/16/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/25/2023]
Abstract
Although blood pressure variability (BPV) and reperfusion are associated with parenchymal hematoma (PH) after stroke, the relationship between BPV and PH in atrial fibrillation (AF) patients who are at risk of reperfusion injury with frequent spontaneous recanalization is unknown. This study aimed to investigate whether BPV within the first 48 h is associated with PH within 72 h in patients with AF and stroke in terms of major vessel occlusion status. A total of 131 patients with AF that were admitted within 24 h after stroke onset were enrolled. PH was defined as a confluent hemorrhage with mass effect. The maximum (max), minimum (min), and average blood pressure (BP) during the first 48 h after admission were calculated. BPV was analyzed by using range between maximum and minimum (max-min), successive variation (SV), standard deviation (SD), and coefficient of variation (CV). All parameters were applied for systemic (SBP), diastolic (DBP), and pulse pressure (PP). After adjusting for confounding variables, various BPV parameters were associated with PH, including SBPmax (p = 0.0426), SBPSV (p = 0.0006), DBPmax-min (p = 0.0437), DBPSV (p = 0.0358), DBPSD (p = 0.0393), PPmax-min (p = 0.0478), PPSV (p < 0.0001), PPSD (p = 0.0034), and PPCV (p = 0.0120). The relationship remained significant in patients with a patent major vessel responsible for infarction but not in patients with an occluded major vessel. In conclusion, this study revealed that high BPV was associated with PH in patients with AF and acute stroke, particularly for those with a patent major vessel. The control of BP and BPV after stroke may be considered in patients with AF.
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Affiliation(s)
- Meng-Ni Wu
- Departments of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Departments of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Peng Liu
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-On Fong
- Departments of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yi-Hui Lin
- Departments of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - I-Hsiao Yang
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ping-Song Chou
- Departments of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Departments of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chung-Yao Hsu
- Departments of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Departments of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiu-Fen Lin
- Departments of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
- Departments of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Palaiodimou L, Joundi RA, Katsanos AH, Ahmed N, Kim JT, Goyal N, Maier IL, de Havenon A, Anadani M, Matusevicius M, Mistry EA, Khatri P, Arthur AS, Sarraj A, Yaghi S, Shoamanesh A, Catanese L, Psychogios MN, Malhotra K, Spiotta AM, Vassilopoulou S, Tsioufis K, Sandset EC, Alexandrov AV, Petersen N, Tsivgoulis G. Association between blood pressure variability and outcomes after endovascular thrombectomy for acute ischemic stroke: An individual patient data meta-analysis. Eur Stroke J 2024; 9:88-96. [PMID: 37921233 PMCID: PMC10916831 DOI: 10.1177/23969873231211157] [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: 08/29/2023] [Accepted: 10/14/2023] [Indexed: 11/04/2023] Open
Abstract
INTRODUCTION Data on the association between blood pressure variability (BPV) after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) and outcomes are limited. We sought to identify whether BPV within the first 24 hours post EVT was associated with key stroke outcomes. METHODS We combined individual patient-data from five studies among AIS-patients who underwent EVT, that provided individual BP measurements after the end of the procedure. BPV was estimated as either systolic-BP (SBP) standard deviation (SD) or coefficient of variation (CV) over 24 h post-EVT. We used a logistic mixed-effects model to estimate the association [expressed as adjusted odds ratios (aOR)] between tertiles of BPV and outcomes of 90-day mortality, 90-day death or disability [modified Rankin Scale-score (mRS) > 2], 90-day functional impairment (⩾1-point increase across all mRS-scores), and symptomatic intracranial hemorrhage (sICH), adjusting for age, sex, stroke severity, co-morbidities, pretreatment with intravenous thrombolysis, successful recanalization, and mean SBP and diastolic-BP levels within the first 24 hours post EVT. RESULTS There were 2640 AIS-patients included in the analysis. The highest tertile of SBP-SD was associated with higher 90-day mortality (aOR:1.44;95% CI:1.08-1.92), 90-day death or disability (aOR:1.49;95% CI:1.18-1.89), and 90-day functional impairment (adjusted common OR:1.42;95% CI:1.18-1.72), but not with sICH (aOR:1.22;95% CI:0.76-1.98). Similarly, the highest tertile of SBP-CV was associated with higher 90-day mortality (aOR:1.33;95% CI:1.01-1.74), 90-day death or disability (aOR:1.50;95% CI:1.19-1.89), and 90-day functional impairment (adjusted common OR:1.38;95% CI:1.15-1.65), but not with sICH (aOR:1.33;95% CI:0.83-2.14). CONCLUSIONS BPV after EVT appears to be associated with higher mortality and disability, independently of mean BP levels within the first 24 h post EVT. BPV in the first 24 h may be a novel target to improve outcomes after EVT for AIS.
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Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Raed A Joundi
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Aristeidis H Katsanos
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ilko L Maier
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Mohammad Anadani
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Marius Matusevicius
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Amrou Sarraj
- Department of Neurology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY, USA
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Luciana Catanese
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Sofia Vassilopoulou
- First Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nils Petersen
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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9
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Park H, Sohn SI, Leem GH, Kim M, Kim YH, Song TJ. Standard Versus Intensive Blood Pressure Control in Acute Ischemic Stroke Patients Successfully Treated With Endovascular Thrombectomy: A Systemic Review and Meta-Analysis of Randomized Controlled Trials. J Stroke 2024; 26:54-63. [PMID: 38326706 PMCID: PMC10850446 DOI: 10.5853/jos.2023.04119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND AND PURPOSE The optimal blood pressure (BP) control after successful endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) with large vessel occlusion (LVO) remains debatable. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that evaluate the efficacy and safety of standard BP control (with systolic BP ≤180 mm Hg) versus intensive BP control (systolic BP <140 mm Hg) during the 24 hours after successful EVT in AIS with LVO. METHODS PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Embase were searched to identify relevant trials. The crude odds ratio (OR) and 95% confidence interval (CI) were calculated and estimates using random-effects models were pooled. This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO ID: CRD42023450673). RESULTS Four RCTs involving 1,559 participants were included. Regarding efficacy outcomes, intensive BP control was associated with a lower likelihood of functional independence (OR: 0.68; 95% CI: 0.51-0.91 for modified Rankin Scale [mRS] ≤2) and walking without assistance (OR: 0.65; 95% CI: 0.53-0.81 for mRS ≤3). For safety outcomes, consistent with the efficacy findings, intensive BP control was significantly associated with severe disability or death (mRS 5 or 6) (OR: 1.34; 95% CI: 1.07-1.69). However, there were no significant differences including all-cause mortality, any intracerebral hemorrhage (ICH), symptomatic ICH, parenchymal hematoma type 2, and stroke recurrence. CONCLUSION While all four RCTs were conducted to demonstrate the superiority of intensive BP control over standard BP control, standard BP control may be beneficial for the outcome after EVT for AIS with LVO without increasing adverse safety outcomes. Caution should be needed with the application of intensive BP control during the 24 hours following successful recanalization after EVT.
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Affiliation(s)
- Hyungjong Park
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Gwang Hyun Leem
- Department of Convergence Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Minho Kim
- Department of Convergence Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Yun Hak Kim
- Department of Anatomy, School of Medicine, Pusan National University, Yangsan, Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
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Cascio Rizzo A, Schwarz G, Cervo A, Giussani G, Ceresa C, Gatti A, De Angeli F, Motto C, Guccione A, Tortorella R, Granata G, Rollo C, Macera A, Piano M, Pero G, Agostoni EC. Safety and efficacy of endovascular thrombectomy for primary and secondary MeVO. J Stroke Cerebrovasc Dis 2024; 33:107492. [PMID: 37988832 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107492] [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: 06/15/2023] [Revised: 09/17/2023] [Accepted: 11/15/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Medium-vessel occlusions (MeVO) are emerging as a new target for endovascular treatment (EVT). Primary MeVO occur de novo, while secondary MeVO arise from large vessel occlusion (LVO) through clot migration or fragmentation - spontaneously, following intravenous thrombolysis or EVT. We aimed to evaluate efficacy and safety of EVT in primary and EVT-induced secondary MeVO. METHODS Retrospective single-center study on consecutive EVT-treated acute ischemic stroke, from 2019-to-2021. We considered: (1) exclusive-LVO, patients with LVO and - in case of residual distal occlusion - no rescue endovascular procedure; (2) primary MeVO: initial A2, A3, M2 non-dominant, M3, P2, P3 occlusions; (3) EVT-induced secondary MeVO, presenting LVO with subsequent (treated) EVT-induced MeVO. We compared (univariable/multivariable logistic regression) EVT efficacy (eTICI≥2b, 3-month modified Rankin Scale [mRS] 0-2) and safety (EVT-complications [vessel dissection, perforation, persistent-SAH], symptomatic ICH) in all MeVO versus exclusive-LVO, primary MeVO versus exclusive-LVO, EVT-induced secondary MeVO versus exclusive-LVO and EVT-induced secondary MeVO versus primary MeVO. RESULTS We included 335 patients: 221 (66.0 %) exclusive-LVO and 114 (34.0 %) MeVO (55 [48.2 %] primary, 59 [51.8 %] secondary). Compared to exclusive-LVO, primary MeVO had higher rates of EVT complications (aOR 3.77 [95%CI 1.58-9.00],p=0.003), lower rates of eTICI≥2b (aOR 0.32 [95%CI 0.12-0.88],p=0.027) and mRS 0-2 (aOR 0.28 [95%CI 0.13-0.63],p=0.002). EVT-induced secondary MeVO had no major differences in efficacy and safety outcomes compared to exclusive-LVO, but a better mRS 0-2 (aOR 8.00 [95%CI 2.12-30.17],p=0.002) compared to primary MeVO. CONCLUSIONS Primary and EVT-induced secondary MeVO showed different safety/efficacy EVT-related profiles. Dedicated randomized data are needed to identify the best acute reperfusion strategy in the two categories.
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Affiliation(s)
- Angelo Cascio Rizzo
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Ghil Schwarz
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Amedeo Cervo
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuditta Giussani
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Chiara Ceresa
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonella Gatti
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fausto De Angeli
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Cristina Motto
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Angelo Guccione
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Rachele Tortorella
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Granata
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Rollo
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Macera
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mariangela Piano
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Guglielmo Pero
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elio Clemente Agostoni
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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11
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Wada T, Takayama K, Myouchin K, Kishida H, Chanoki Y, Oshima K, Masutani T, Uchiyama Y, Tanaka T. Symptomatic Intracranial Hemorrhage after Mechanical Thrombectomy - the Difference between Iso-Osmolar and Low-Osmolar Contrast Media. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 18:18-23. [PMID: 38260038 PMCID: PMC10800169 DOI: 10.5797/jnet.oa.2023-0074] [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: 10/10/2023] [Accepted: 11/12/2023] [Indexed: 01/24/2024]
Abstract
Objective Symptomatic intracranial hemorrhage (SICH) after mechanical thrombectomy (MT) is generally considered a critical complication. Hemorrhagic transformation after ischemic stroke has also been associated with contrast media administration. The objective of our study was to evaluate correlations between contrast media type and incidence of SICH after MT. Methods Ninety-three consecutive patients (41 men; mean age, 80.2 years; range, 44-98 years) underwent MT reperfusion (expanded thrombolysis in cerebral infarction score, 2a-3) for acute large-vessel occlusion ischemic stroke within 8 h after symptom onset between April 2020 and July 2023 were retrospectively reviewed. Correlations between contrast media type (iso-osmolar or low-osmolar medium) and incidence of SICH were assessed. Results Contrast media were iso-osmolar in 60 cases or low-osmolar in 33 cases. The overall incidence of SICH was 5.5%. The frequency of SICH was significantly lower in the iso-osmolar group (1.7%) than in the low-osmolar group (12.1%; P = 0.033). Conclusion Iso-osmolar contrast media was associated with a lower incidence of SICH compared with low-osmolar contrast media in patients after MT.
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Affiliation(s)
- Takeshi Wada
- Department of Interventional Neuroradiology/Radiology, Kouseikai Takai Hospital, Tenri, Nara, Japan
| | - Katsutoshi Takayama
- Department of Interventional Neuroradiology/Radiology, Kouseikai Takai Hospital, Tenri, Nara, Japan
| | - Kaoru Myouchin
- Department of Interventional Neuroradiology/Radiology, Kouseikai Takai Hospital, Tenri, Nara, Japan
| | - Hayato Kishida
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Chanoki
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Keisuke Oshima
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Takahiro Masutani
- Departments of Neurosurgery, Ishinkai Yao General Hospital, Yao, Osaka, Japan
| | - Yoshitomo Uchiyama
- Departments of Neurosurgery, Ishinkai Yao General Hospital, Yao, Osaka, Japan
| | - Toshihiro Tanaka
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
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12
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Migdady I, Johnson-Black PH, Leslie-Mazwi T, Malhotra R. Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke. J Clin Med 2023; 12:6641. [PMID: 37892779 PMCID: PMC10607145 DOI: 10.3390/jcm12206641] [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: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.
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Affiliation(s)
- Ibrahim Migdady
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Phoebe H. Johnson-Black
- Department of Neurosurgery, Division of Neurocritical Care, UCLA David Geffen School of Medicine, Ronald Reagan Medical Center, Los Angeles, CA 90095, USA;
| | | | - Rishi Malhotra
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
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13
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Nakagawa I, Kotsugi M, Yokoyama S, Maeoka R, Takeshima Y, Matsuda R, Yamada S, Nakase H. Parenchymal Blood Volume Changes Immediately After Endovascular Thrombectomy Predict Futile Recanalization in Patients with Emergent Large Vessel Occlusion. World Neurosurg 2023; 176:e711-e718. [PMID: 37295462 DOI: 10.1016/j.wneu.2023.06.006] [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: 01/15/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE More than one third of acute ischemic stroke (AIS) patients do not recover to functional independence even if endovascular thrombectomy (EVT) is performed rapidly and successfully. This suggests that angiographic recanalization does not necessarily lead to tissue reperfusion. Although recognition of reperfusion status after EVT is pivotal for optimal postoperative management, reperfusion imaging assessment immediately after recanalization has not been fully investigated. The present study aimed to evaluate whether reperfusion status based on parenchymal blood volume (PBV) assessment after angiographic recanalization influences infarct growth and functional outcome in patients who have undergone EVT following AIS. METHODS Seventy-nine patients who underwent successful EVT for AIS were retrospectively analyzed. PBV maps were acquired from flat-panel detector computed tomography (CT) perfusion images before and after angiographic recanalization. Reperfusion status was assessed from PBV values and their changes in regions of interest and collateral score. RESULTS Post-EVT PBV ratio and ΔPBV ratio, as PBV parameters indicating the degree of reperfusion, were significantly lower in the unfavorable prognosis group (P < 0.01 each). Poor reperfusion on PBV mapping was associated with significantly longer puncture-to-recanalization time, lower collateral score, and higher frequency of infarct growth. Logistic regression analysis identified low collateral score and low ΔPBV ratio as associated with poor prognosis after EVT (odds ratios, 2.48, 3.72; 95% confidence intervals, 1.06-5.81, 1.20-11.53; P = 0.04, 0.02, respectively). CONCLUSIONS Poor reperfusion in severely hypoperfused territories on PBV mapping immediately after recanalization may predict infarct growth and unfavorable prognosis in patients who undergo EVT following AIS.
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Affiliation(s)
- Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Nara, Japan.
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Shohei Yokoyama
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Ryosuke Maeoka
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | | | - Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Nara, Japan
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14
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Gao L, Li Z, Yuan Z, Yi X, Li J, Cui C, Chen N, He L. Major intracranial arterial stenosis influence association between baseline blood pressure and clinical outcomes after thrombolysis in ischemic stroke patients. Brain Behav 2023; 13:e3022. [PMID: 37218397 PMCID: PMC10275514 DOI: 10.1002/brb3.3022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/31/2023] [Accepted: 02/28/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND This study aimed to investigate the relationship between baseline blood pressure (BP) and clinical outcomes after thrombolysis for acute ischemic stroke (AIS) in different intracranial arterial stenosis subgroups. METHODS AIS patients from multicenter with intravenous thrombolysis were retrospectively enrolled from January 2013 to December 2021. We categorized participants into severe (≥ 70%) and nonsevere (< 70%) stenosis of major intracranial arteries subgroups. The primary outcome was unfavorable functional outcome defined as 3-month modified Rankin Scale (mRS) ≥2. The association coefficients between baseline BP and functional outcomes were estimated in general linear regression model. The interactive effect was tested to determine the influence of intracranial arterial stenosis on the association between BP and clinical outcomes. RESULTS A total of 329 patients were included. Severe subgroup was detected in 151 patients with average age of 70.5. Association between baseline diastolic BP (DBP) and unfavorable functional outcome in intracranial artery stenosis subgroups was significantly different (p for interaction < .05). In nonsevere subgroup, higher baseline DBP was associated with higher risk of unfavorable outcome (OR 1.11, 95% CI 1.03 to 1.20, p = .009) compared with severe subgroup (OR 1.02, 95% CI 0.97 to 1.08, p = .341). Besides, intracranial artery stenosis also modified association between baseline systolic BP (SBP) and 3-month death (p for interaction < .05). In severe subgroup, higher baseline SBP was associated with decreased 3-month death risk (OR 0.88, 95% CI 0.78 to 1, p = .044) compared with nonsevere subgroup (OR 1, 95% CI 0.93 to 1.07, p = .908). CONCLUSIONS The major intracranial artery state modulates association between baseline BP and 3-month clinical outcomes after intravenous thrombolysis.
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Affiliation(s)
- Lijie Gao
- Department of NeurologyWest China Hospital of Sichuan UniversityChengduChina
| | - Zuoxiao Li
- Department of NeurologyAffiliated Hospital of Southwest Medical UniversityLuzhouChina
| | - Zhengzhou Yuan
- Department of NeurologyAffiliated Hospital of Southwest Medical UniversityLuzhouChina
| | - Xingyang Yi
- Department of NeurologyPeople's Hospital of Deyang CityDeyangChina
| | - Jie Li
- Department of NeurologyPeople's Hospital of Deyang CityDeyangChina
| | - Chaohua Cui
- Department of NeurologyWest China Hospital of Sichuan UniversityChengduChina
| | - Ning Chen
- Department of NeurologyWest China Hospital of Sichuan UniversityChengduChina
| | - Li He
- Department of NeurologyWest China Hospital of Sichuan UniversityChengduChina
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15
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Fujiwara S, Sakai N, Imamura H, Ohara N, Tanaka K, Yamagami H, Matsumoto Y, Takeuchi M, Uchida K, Yoshimura S, Morimoto T. Impact of thrombocytopenia on hemorrhagic complications after endovascular therapy for acute large vessel occlusion: Sub-analysis of RESCUE-Japan registry 2. J Neurol Sci 2023; 449:120659. [PMID: 37079972 DOI: 10.1016/j.jns.2023.120659] [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: 01/09/2023] [Revised: 03/14/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Endovascular treatment (EVT) for patients with large vessel occlusion (LVO) and concurrent thrombocytopenia raises concerns about hemorrhagic complications. We examined the association between thrombocytopenia and clinical outcomes after EVT. METHODS This is a sub-analysis of the RESCUE-Japan Registry 2, a nationwide registry that enrolled 2420 consecutive acute LVO patients. We evaluated the clinical outcomes in patients who underwent EVT according to their platelet count on admission (Moderate/Severe, < 100 × 109 /L; Mild, 100 to ≤150 × 109/L; Normal, ≥ 150 × 109/L). The outcomes included any and symptomatic intracranial hemorrhage (ICH) after EVT, and modified Rankin Scale (mRS) at 90 days. RESULTS Of 1268 patients who underwent EVT, the Moderate/Severe and Mild groups consisted of 41 (3.2%), and 193 (15.2%) patients. Any ICH occurred in 37%, 35%, and 24% of Moderate/Severe, Mild, and Normal group patients, respectively, and the adjusted ORs (95% CIs) were 1.50 (0.71-3.18) for Moderate/Severe and 1.87 (1.28-2.73) for Mild, compared to the Normal group (p for trend = 0.004). Symptomatic ICH increased with the severity of thrombocytopenia (9.8% vs 3.6% vs 2.1%), and adjusted ORs were 4.43 (1.16-17.0) in Moderate/Severe and 1.85 (0.71-4.86) in Mild (p for trend = 0.10). Mortality was significantly associated with the severity of thrombocytopenia (p for trend = 0.005), and adjusted ORs were 3.26 (1.29-8.26) in the Moderate/Severe and 2.76 (1.58-4.84) in the Mild groups. CONCLUSIONS Thrombocytopenia in LVO patients was not rare and associated with the incidence and manifestation of ICH after EVT.
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Affiliation(s)
- Satoru Fujiwara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan; Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan; Division of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuyuki Ohara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | | | - Kazutaka Uchida
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan; Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan.
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16
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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.
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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
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17
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Schwarz G, Cascio Rizzo A, Matusevicius M, Giussani G, Invernizzi P, Melis F, Lesko N, Toni D, Agostoni EC, Ahmed N. Reperfusion Treatments in Disabling Versus Nondisabling Mild Stroke due to Anterior Circulation Vessel Occlusion. Stroke 2023; 54:743-750. [PMID: 36848431 DOI: 10.1161/strokeaha.122.041772] [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: 03/01/2023]
Abstract
BACKGROUND The benefit of distinguishing between disabling versus nondisabling deficit in mild acute ischemic stroke due to endovascular thrombectomy-targetable vessel occlusion (EVT-tVO; including anterior circulation large and medium-vessel occlusion) is unknown. We compared safety and efficacy of acute reperfusion treatments in disabling versus nondisabling mild EVT-tVO. METHODS From the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register, we included consecutive acute ischemic stroke patients (2015-2021) treated within 4.5 hours, with full NIHSS items availability and score ≤5, evidence of intracranial internal carotid artery, M1, A1-2, or M2-3 occlusion. After propensity score matching, we compared efficacy (3-month modified Rankin Scale score of 0-1, modified Rankin Scale score of 0-2, and early neurological improvement) and safety (nonhemorrhagic early neurological deterioration, any intracerebral or subarachnoid hemorrhage, symptomatic intracranial hemorrhage, and death at 3-month) outcomes in disabling versus nondisabling patients-adopting an available definition. RESULTS We included 1459 patients. Propensity score matched analysis of disabling versus nondisabling EVT-tVO (n=336 per group) found no significant differences in efficacy (modified Rankin Scale score 0-1: 67.4% versus 71.5%, P=0.336; modified Rankin Scale score 0-2: 77.1% versus 77.6%, P=0.895; early neurological improvement: 38.3% versus 44.4%, P=0.132) and safety (nonhemorrhagic early neurological deterioration: 8.5% versus 8.0%, P=0.830; any intracerebral hemorrhage or subarachnoid hemorrhage: 12.5% versus 13.3%, P=0.792; symptomatic intracranial hemorrhage: 2.6% versus 3.4%, P=0.598; and 3-month death: 9.8% versus 9.2%, P=0.844) outcomes. CONCLUSIONS We found similar safety and efficacy outcomes after acute reperfusion treatment in disabling versus nondisabling mild EVT-tVO; our findings suggest to adopt similar acute treatment approaches in the 2 groups. Randomized data are needed to clarify the best reperfusion treatment in mild EVT-tVO.
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Affiliation(s)
- Ghil Schwarz
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (G.S., A.C.R., G.G., E.C.A.).,Stroke Research Centre, University College London, Institute of Neurology, UK (G.S.)
| | - Angelo Cascio Rizzo
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (G.S., A.C.R., G.G., E.C.A.)
| | - Marius Matusevicius
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (M.M., N.A.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.M., N.A.)
| | - Giuditta Giussani
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (G.S., A.C.R., G.G., E.C.A.).,Department of Neurology - Stroke Unit, Ospedale San Giuseppe MultiMedica IRCCS, Milano, Italy (G.G.)
| | - Paolo Invernizzi
- Neuroradiology and Neurology Units, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (P.I.)
| | - Fabio Melis
- S.S. Neurovascolare, ASL Città di Torino, Ospedale Maria Vittoria, Italia (F.M.)
| | - Norbert Lesko
- Department of Neurology, P.J. Safarik University, Kosice, Slovakia (N.L.)
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Italy (D.T.)
| | - Elio Clemente Agostoni
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (G.S., A.C.R., G.G., E.C.A.)
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (M.M., N.A.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.M., N.A.)
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18
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Efficacy of Early Intensive Blood Pressure Management After Thrombectomy: Protocol for a Randomized Controlled Clinical Trial (IDENTIFY). Neurocrit Care 2023; 38:196-203. [PMID: 36329307 DOI: 10.1007/s12028-022-01618-9] [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: 07/25/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The optimal strategy for blood pressure management after thrombectomy remains unknown. The primary objective of The Early Intensive Blood Pressure Management after Endovascular Thrombectomy (IDENTIFY) study is to explore the efficacy and safety of early intensive blood pressure management strategies after thrombectomy compared with that of standard management. METHODS The IDENTIFY study is a prospective, randomized, open-label, assessor-blinded multicenter clinical trial. Patients with acute anterior circulation ischaemic stroke who underwent endovascular thrombectomy within 6 h of stroke onset, achieved successful recanalization, and had two consecutive blood pressure readings > 130 mm Hg during the first 6 h after thrombectomy will be enrolled and centrally randomized into intensive or standard management groups in a 1:1 ratio. Continuous blood pressure monitoring will be initiated at the end of thrombectomy, and patients with high blood pressure during the transfer to the wards will also be enrolled. For patients in the intensive management group, the target blood pressure will be < 130 mm Hg, and the use of antihypertensive drugs will be discontinued if systolic blood pressure goes below 110 mm Hg. The target blood pressure for the standard management group will be < 180 mm Hg, and if systolic blood pressure decreases below 140 mm Hg, the use of antihypertensive drugs will be stepwise decreased until the systolic blood pressure reaches 140 mm Hg again or the infusion is discontinued. Patients will have their blood pressure reduced to the target range within 1 h from randomization and maintained until 24 h after thrombectomy with intravenous hypertensive drugs. A sample size of 600 was predicted. The primary outcome will be the rate of dependency (modified Rankin Scale scores 3-6) at 90 days. Secondary outcomes will include intracerebral hemorrhage (either symptomatic or asymptomatic) within 24 h and 7 days, malignant brain oedema, all-cause death, death and severe disability at 90 days, and quality of life at 90 days, which will be measured using the EuroQol-5 Dimensions-5 Level (EQ-5D-5L) and the 36-Item Short Form Health Survey (SF-36). Safety outcomes will include stroke recurrence within 24 h, early neurological deterioration, hypotension within 24 h, death within 7 days after endovascular thrombectomy, and all-cause acute kidney injury. Trial registration chictr.org.cn (identifier: ChiCTR2200057770). Registered March 17, 2022, http://www.chictr.org.cn/edit.aspx?pid=162575&htm=4.
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19
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Anaesthetic and peri-operative management for thrombectomy procedures in stroke patients. Anaesth Crit Care Pain Med 2023; 42:101188. [PMID: 36599377 DOI: 10.1016/j.accpm.2022.101188] [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: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE To provide recommendations for the anaesthetic and peri-operative management for thrombectomy procedure in stroke patients DESIGN: A consensus committee of 15 experts issued from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation, SFAR), the Association of French-language Neuro-Anaesthetists (Association des Neuro-Anesthésistes Réanimateurs de Langue Francaise, ANARLF), the French Neuro-Vascular Society (Société Francaise de Neuro-Vasculaire, SFNV), the French Neuro-Radiology Society (Société Francaise de Neuro-Radiologie, SFNR) and the French Study Group on Haemostasis and Thrombosis (Groupe Français d'Études sur l'Hémostase et la Thrombose, GFHT) was convened, under the supervision of two expert coordinators from the SFAR and the ANARLF. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were required to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. METHODS Four fields were defined prior to the literature search: (1) Peri-procedural management, (2) Prevention and management of secondary brain injuries, (3) Management of antiplatelet and anticoagulant treatments, (4) Post-procedural management and orientation of the patient. Questions were formulated using the PICO format (Population, Intervention, Comparison, and Outcomes) and updated as needed. Analysis of the literature was then conducted and the recommendations were formulated according to the GRADE methodology. RESULTS The SFAR/ANARLF/SFNV/SFNR/GFHT guideline panel drew up 18 recommendations regarding anaesthetic management of mechanical thrombectomy procedures. Due to a lack of data in the literature allowing to conclude with high certainty on relevant clinical outcomes, the experts decided to formulate these guidelines as "Professional Practice Recommendations" (PPR) rather than "Formalized Expert Recommendations". After two rounds of rating and several amendments, a strong agreement was reached on 100% of the recommendations. No recommendation could be formulated for two questions. CONCLUSIONS Strong agreement among experts was reached to provide a sizable number of recommendations aimed at optimising anaesthetic management for thrombectomy in patients suffering from stroke.
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20
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Widimsky P, Snyder K, Sulzenko J, Hopkins LN, Stetkarova I. Acute ischaemic stroke: recent advances in reperfusion treatment. Eur Heart J 2022; 44:1205-1215. [PMID: 36477996 PMCID: PMC10079392 DOI: 10.1093/eurheartj/ehac684] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
During the last 5–7 years, tremendous progress was achieved in the reperfusion treatment of acute ischaemic stroke during its first few hours from symptom onset. This review summarizes the latest evidence from randomized clinical trials and prospective registries with a focus on endovascular treatment using stent retrievers, aspiration catheters, thrombolytics, and (in selected patients) carotid stenting. Novel approaches in prehospital (mobile interventional stroke teams) and early hospital (direct transfer to angiography) management are described, and future perspectives (‘all-in-one’ laboratories with angiography and computed tomography integrated) are discussed. There is reasonable chance for patients with moderate-to-severe acute ischaemic stroke to survive without permanent sequelae when the large-vessel occlusion is removed by means of modern pharmaco-mechanic approach. Catheter thrombectomy is now the golden standard of acute stroke treatment. The role of cardiologists in stroke is expanding from diagnostic help (to reveal the cause of stroke) to acute therapy in those regions where such up-to-date Class I. A treatment is not yet available.
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Affiliation(s)
- Petr Widimsky
- Cardiocenter, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
| | - Kenneth Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY , USA
| | - Jakub Sulzenko
- Cardiocenter, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
| | - Leo Nelson Hopkins
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY , USA
| | - Ivana Stetkarova
- Department of Neurology at the Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
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21
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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: 78] [Impact Index Per Article: 39.0] [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.
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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.
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22
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Qaryouti D, Greene-Chandos D. Neurocritical Care Aspects of Ischemic Stroke Management. Crit Care Clin 2022; 39:55-70. [DOI: 10.1016/j.ccc.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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23
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Hill M, Baumann JJ, Newcommon N. Nursing Care of the Acute Ischemic Stroke Endovascular Thrombectomy Patient. Stroke 2022; 53:2958-2966. [PMID: 35722874 DOI: 10.1161/strokeaha.122.034536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nurses are an integral part of the multidisciplinary team caring for a patient eligible for endovascular thrombectomy. Their care includes obtaining health history, performing clinical assessments, using critical thinking to anticipate the care path, and communicating findings to other team members. The prehospital and emergency department nurses utilize stroke severity scales to identify a possible thrombectomy candidate and help expedite intervention. In the interventional laboratory, nursing collaborates with radiology technologists and interventionalists to ensure patient safety and monitor for intraprocedural complications. Post-procedure, the intensive care nurse delivers complex care to ensure optimal neurological outcome and assess for postprocedural complications. Nursing is essential in every phase of care along with collaboration with other disciplines.
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Affiliation(s)
- Michelle Hill
- OhioHealth-Riverside Methodist Hospital, Columbus (M.H.)
| | - J J Baumann
- UCHealth Memorial Hospital, Colorado Springs, CO (J.J.B.)
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24
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Bath PM, Song L, Silva GS, Mistry E, Petersen N, Tsivgoulis G, Mazighi M, Bang OY, Sandset EC. Blood Pressure Management for Ischemic Stroke in the First 24 Hours. Stroke 2022; 53:1074-1084. [PMID: 35291822 DOI: 10.1161/strokeaha.121.036143] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High blood pressure (BP) is common after ischemic stroke and associated with a poor functional outcome and increased mortality. The conundrum then arises on whether to lower BP to improve outcome or whether this will worsen cerebral perfusion due to aberrant cerebral autoregulation. A number of large trials of BP lowering have failed to change outcome whether treatment was started prehospital in the community or hospital. Hence, nuances on how to manage high BP are likely, including whether different interventions are needed for different causes, the type and timing of the drug, how quickly BP is lowered, and the collateral effects of the drug, including on cerebral perfusion and platelets. Specific scenarios are also important, including when to lower BP before, during, and after intravenous thrombolysis and endovascular therapy/thrombectomy, when it may be necessary to raise BP, and when antihypertensive drugs taken before stroke should be restarted. This narrative review addresses these and other questions. Although further large trials are ongoing, it is increasingly likely that there is no simple answer. Different subgroups of patients may need to have their BP lowered (eg, before or after thrombolysis), left alone, or elevated.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (P.M.B.)
| | - Lili Song
- The George Institute China at Peking University Health Science Center, Beijing (L.S.)
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Sydney, Australia (L.S.)
| | - Gisele S Silva
- Neurology, Federal University of São Paulo (UNIFESP) and Hospital Israelita Albert Einstein, Brazil (G.S.S.)
| | - Eva Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (E.M.)
| | - Nils Petersen
- Department of Neurology, Divisions of Vascular Neurology and Neurocritical Care, Yale School of Medicine, New Haven (N.P.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (G.T.)
| | - Mikael Mazighi
- Department of Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris, INSERM 1148, FHU Neurovasc, France (M.M.)
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.)
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Norway (E.C.S.)
- The Norwegian Air Ambulance Foundation, Oslo (E.C.S.)
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25
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Sengeze N, Ozdemir Ö, Eren A, Aykac Ö, Sarıönder Gencer E, Giray S, Yurekli V, Yıldırım S, Akpınar ÇK, Inanc Y, Acar BA, Baydemir R, Milanlioglu A, Cenikli U, Ozkul A, Gurkas E, Aytac E, Cabalar M, Gokce M, Bas DF, Asil T, Sair A, Karaibrahimoglu A. Predictors of Symptomatic Hemorrhage After Endovascular Treatment for Anterior Circulation Occlusions: Turkish Endovascular Stroke Registry. Angiology 2022; 73:835-842. [PMID: 35249358 DOI: 10.1177/00033197221082711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We evaluated the predictive factors of symptomatic intracranial hemorrhage (SICH) in endovascular treatment of stroke. We included 975 ischemic stroke patients with anterior circulation occlusion. Patients that had hemorrhage and an increase of ≥4 points in their National Institutes of Health Stroke Scale (NIHSS) after the treatment were considered as SICH. The mean age of patients was 65.2±13.1 years and 469 (48.1%) were women. The median NIHSS was 16 (13-18) and Alberta Stroke Program Early CT 9 (8-10). In 420 patients (43.1%), modified Rankin Scale was favorable (0-2) and mortality was observed in 234 (24%) patients at the end of the third month. Patients with high diastolic blood pressure (P<.05) had significantly higher SICH. SICH was significantly higher in those with high NIHSS scores (P<.001), high blood glucose (P<.001), and leukocyte count at admission (P<.05). Diabetes mellitus (DM) (OR 1.90; P<.001), NIHSS (OR 1.07; P<.05), adjuvant intra-arterial thrombolytic therapy (IA-rtPA) (OR, 1.60; P<.05), and puncture-recanalization time (OR 1.01; P<.05) were independent factors of SICH. Higher baseline NIHSS score, longer procedure time, multiple thrombectomy maneuvers, administration of IA-rtPA, and the history of DM are independent predictors of SICH in anterior circulation occlusion.
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Affiliation(s)
- Nihat Sengeze
- Department of Neurology, RinggoldID:64077Suleyman Demirel University Hospital, Isparta, Turkey
| | - Özcan Ozdemir
- Department of Neurology, Osmangazi University Hospital, Eskisehir, Turkey
| | - Alper Eren
- Department of Neurology, Ataturk University Hospital, Erzurum, Turkey
| | - Özlem Aykac
- Department of Neurology, Osmangazi University Hospital, Eskisehir, Turkey
| | - Elif Sarıönder Gencer
- Department of Neurology, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey
| | - Semih Giray
- Department of Neurology, Gaziantep University Hospital, Gaziantep, Turkey
| | - Vedat Yurekli
- Department of Neurology, RinggoldID:64077Suleyman Demirel University Hospital, Isparta, Turkey
| | - Serhan Yıldırım
- Department of Neurology, University of Health Sciences Kocaeli Training and Research Hospital, Kocaeli, Turkey
| | - Çetin K Akpınar
- Department of Neurology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Yusuf Inanc
- Department of Neurology, Gaziantep University Hospital, Gaziantep, Turkey
| | - Bilgehan A Acar
- Department of Neurology, Sakarya University Hospital, Sakarya, Turkey
| | - Recep Baydemir
- Department of Neurology, Erciyes University Hospital, Kayseri, Turkey
| | - Aysel Milanlioglu
- Department of Neurology, Yuzuncu Yil University Hospital, Van, Turkey
| | - Utku Cenikli
- Department of Neurology, University of Health Sciences Mugla Training and Research Hospital, Mugla, Turkey
| | - Ayca Ozkul
- Department of Neurology, Adnan Menders University Medicine Faculty, Aydın, Turkey
| | - Erdem Gurkas
- Department of Neurology, Kartal Dr Lutfi Kırdar Training and Research Hospital, İstanbul, Turkey
| | - Emrah Aytac
- Department of Neurology, Firat University, Elazig, Turkey
| | - Murat Cabalar
- Department of Neurology, İstanbul Bakırkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Gokce
- Department of Neurology, Sutcu Imam University Hospital, Kahramanmaras, Turkey
| | - Demet F Bas
- Department of Neurology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Talip Asil
- Department of Neurology, King Hamad University Hospital, Busaiteen, Kingdom of Baharin
| | - Ahmet Sair
- Department of Neurology, Adnan Menders University Medicine Faculty, Aydın, Turkey
| | - Adnan Karaibrahimoglu
- Department of Statistical Institute, Medicine Faculty of Suleyman Demirel University, Isparta, Turkey
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26
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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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27
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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.
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28
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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.
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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
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29
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Maïer B, Gory B, Lapergue B, Sibon I, Escalard S, Kyheng M, Labreuche J, de Havenon A, Petersen N, Anadani M, Gayat E, Boursin P, Ben Maacha M, Desilles JP, Blanc R, Piotin M, Halimi JM, Mazighi M. Effect of blood pressure variability in the randomized controlled BP TARGET trial. Eur J Neurol 2021; 29:771-781. [PMID: 34821437 DOI: 10.1111/ene.15194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE The Blood Pressure Target in Acute Ischemic Stroke to Reduce Hemorrhage After Endovascular Therapy (BP TARGET) trial evaluated whether an intensive systolic blood pressure (SBP) target resulted in reduced rates of intracranial hemorrhage (ICH) after successful endovascular therapy (EVT) but did not assess the effect of blood pressure variability (BPV) on functional outcomes and ICH occurrence. We sought to evaluate this question in the BP TARGET trial. METHODS We performed a post hoc analysis of the BP TARGET trial and included patients with at least 50% of blood pressure (BP) recordings during the first 24 h after EVT. BPV parameters were SBP and diastolic BP (DBP) coefficient of variation (CV), standard deviation (SD), maximum-minimum (max-min), successive variation (SV), and time rate. The primary outcome was favorable functional outcome (3-month modified Rankin Scale between 0 and 2); the secondary outcome was the rate of ICH at 24 h. RESULTS We included 290 patients (mean number of BP measures = 30.4, SD = 8.0). BPV parameters (SBPSD , SBPmax-min , SBPCV ) were higher in the intensive SBP target group. Only DBP BPV parameters were associated with worse functional outcomes in the unadjusted model (DBPSD , DBPmax-min , DBPCV , and DBPSV ), but not after adjustment. Higher SBPmax-min was associated with worse functional outcomes in Thrombolysis in Cerebral Infarction 2B patients (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.38-1.02), but not in patients with complete reperfusion (OR = 1.27, 95% CI = 0.80-2.02, p for heterogeneity (phet =0.037). None of the BPV parameters was associated with ICH, regardless of the randomization group or the reperfusion grade. CONCLUSIONS BPV was significantly higher in the intensive SBP target group but was not associated with functional outcome or ICH.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,University of Paris, Paris, France.,FHU NeuroVasc, Paris, France.,EA4245-Transplantation, Immunology, and Inflammation, University of Tours, Tours, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, University of Lorraine, Nancy, France.,IADI, INSERM U1254, University of Lorraine, Nancy, France
| | - Bertrand Lapergue
- Division of Neurology, Department of Neurology, Stroke Center, Foch Hospital, Versailles Saint-Quentin-en-Yvelines University, Suresnes, France
| | - Igor Sibon
- Stroke Unit, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Simon Escalard
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France
| | - Maeva Kyheng
- University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France
| | - Julien Labreuche
- University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France
| | - Adam de Havenon
- Neurology Department, University of Utah, Salt Lake City, Utah, USA
| | - Nils Petersen
- Neurocritical Care and Emergency Neurology, Yale School of Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Mohammad Anadani
- Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Etienne Gayat
- University of Paris, Paris, France.,Department of Anesthesiology, Critical Care and Burn Center, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, Paris, France.,INSERM UMR-S 942, Cardiovascular Makers in Stress Conditions, Paris, France
| | - Perrine Boursin
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France
| | - Malek Ben Maacha
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,University of Paris, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Raphael Blanc
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Jean-Michel Halimi
- EA4245-Transplantation, Immunology, and Inflammation, University of Tours, Tours, France.,Nephrology Department, Tours Hospital, Tours, France.,University of Tours, Tours, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,University of Paris, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
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30
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Katsanos AH, Malhotra K, Ahmed N, Seitidis G, Mistry EA, Mavridis D, Kim JT, Veroniki A, Maier I, Matusevicius M, Khatri P, Anadani M, Goyal N, Arthur AS, Sarraj A, Yaghi S, Shoamanesh A, Catanese L, Kantzanou M, Psaltopoulou T, Rentzos A, Psychogios M, Van Adel B, Spiotta AM, Sandset EC, de Havenon A, Alexandrov AV, Petersen NH, Tsivgoulis G. Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis. Neurology 2021; 98:e291-e301. [PMID: 34772799 DOI: 10.1212/wnl.0000000000013049] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). METHODS A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model. RESULTS A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission: 16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT. CONCLUSION Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada .,Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Georgios Seitidis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Paris Descartes University, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Argie Veroniki
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Ilko Maier
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Marius Matusevicius
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mohammad Anadani
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Amrou Sarraj
- Department of Neurology, UT Houston, Houston, Texas, USA
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Luciana Catanese
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Maria Kantzanou
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rentzos
- Diagnostic and Interventional Neuroradiology, Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marios Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Brian Van Adel
- Division of Neurology, Neurosurgery, and Diagnostic Imaging, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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31
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Matusevicius M, Cooray C, Rand VM, Nunes AP, Moreira T, Tassi R, Egido JA, Ollikainen J, Bigliardi G, Holmin S, Ahmed N. Stroke Etiology and Outcomes after Endovascular Thrombectomy: Results from the SITS Registry and a Meta-Analysis. J Stroke 2021; 23:388-400. [PMID: 34649383 PMCID: PMC8521251 DOI: 10.5853/jos.2021.00850] [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: 03/08/2021] [Accepted: 08/04/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE The influence of stroke etiology on outcomes after endovascular thrombectomy (EVT) is not well understood. We aimed to investigate whether stroke etiology subgrouped as large artery atherosclerosis (LAA) and cardiac embolism (CE) influences outcomes in large artery occlusion (LAO) treated by EVT. METHODS We included EVT treated LAO stroke patients registered in the Safe Implementation of Treatment in Stroke (SITS) thrombectomy register between January 1, 2014 and September 3, 2019. Primary outcome was successful reperfusion (modified Treatment in Cerebral Infarction 2b-3). Secondary outcomes were symptomatic intracranial hemorrhage (SICH), 3-month functional independence (modified Ranking Scale 0-2) and death. Multivariable logistic regression models were used for comparisons. In addition, a meta-analysis of aggregate data from the current literature was conducted (PROSPERO, ID 167447). RESULTS Of 7,543 patients, 1,903 (25.2%) had LAA, 3,214 (42.6%) CE, and 2,426 (32.2%) unknown, other, or multiple etiologies. LAA patients were younger (66 vs. 74, P<0.001) and had lower National Institutes of Health Stroke Scale score at baseline (15 vs. 16, P<0.001) than CE patients. Multivariable analyses showed that LAA patients had lower odds of successful reperfusion (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.57 to 0.86) and functional independence (OR, 0.74; 95% CI, 0.63 to 0.85), higher risk of death (OR, 1.44; 95% CI, 1.21 to 1.71), but no difference in SICH (OR, 1.09; 95% CI, 0.71 to 1.66) compared to CE patients. The systematic review found 25 studies matching the criteria. The meta-analysis did not find any difference between etiologies. CONCLUSIONS From the SITS thrombectomy register, we observed a lower chance of reperfusion and worse outcomes after thrombectomy in patients with LAA compared to CE etiology, despite more favorable baseline characteristics. In contrast, the meta-analysis did not find any difference between etiologies with aggregate data.
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Affiliation(s)
- Marius Matusevicius
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
| | - Charith Cooray
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Viiu-Marika Rand
- Department of Neurology, North Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Ana Paiva Nunes
- Stroke Unit, Saint Joseph's Hospital, Central Lisbon University Hospital Centre, Lisbon, Portugal
| | - Tiago Moreira
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Rossana Tassi
- Stroke Unit, University Hospital of Siena, Siena, Italy
| | - Jose Antonio Egido
- Stroke Unit, Department of Neurology, San Carlos Clinical Hospital, Madrid, Spain
| | | | - Guido Bigliardi
- Department of Neuroscience, Neurologal Clinic, Civil Hospital of Baggiovara, University Hospital of Modena, Modena, Italy
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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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.
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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
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33
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Peng TJ, Ortega-Gutiérrez S, de Havenon A, Petersen NH. Blood Pressure Management After Endovascular Thrombectomy. Front Neurol 2021; 12:723461. [PMID: 34539562 PMCID: PMC8446280 DOI: 10.3389/fneur.2021.723461] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
Endovascular thrombectomy (EVT) has changed the landscape of acute stroke therapy and has become the standard of care for selected patients presenting with anterior circulation large-vessel occlusion (LVO) stroke. Despite successful reperfusion, many patients with LVO stroke do not regain functional independence. Particularly, patients presenting with extremes of blood pressure (BP) or hemodynamic variability are found to have a worse clinical recovery, suggesting blood pressure optimization as a potential neuroprotective strategy. Current guidelines acknowledge the lack of randomized trials to evaluate the optimal hemodynamic management during the immediate post-stroke period. Following reperfusion, lower blood pressure targets may be warranted to prevent reperfusion injury and promote penumbral recovery, but adequate BP targets adjusted to individual patient factors such as degree of reperfusion, infarct size, and overall hemodynamic status remain undefined. This narrative review outlines the physiological mechanisms of BP control after EVT and summarizes key observational studies and clinical trials evaluating post-EVT BP targets. It also discusses novel treatment strategies and areas of future research that could aid in the determination of the optimal post-EVT blood pressure.
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Affiliation(s)
- Teng J Peng
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Santiago Ortega-Gutiérrez
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Adam de Havenon
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
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34
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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.
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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
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35
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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: 4] [Impact Index Per Article: 1.3] [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.
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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
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36
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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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37
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[Focus on neurological intensive care medicine. Intensive care studies from 2020/2021]. Anaesthesist 2021; 70:706-713. [PMID: 34191035 PMCID: PMC8243294 DOI: 10.1007/s00101-021-00977-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 11/10/2022]
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38
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Sandset EC, Anderson CS, Bath PM, Christensen H, Fischer U, Gąsecki D, Lal A, Manning LS, Sacco S, Steiner T, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J 2021; 6:XLVIII-LXXXIX. [PMID: 34780578 PMCID: PMC8370078 DOI: 10.1177/23969873211012133] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/05/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke.The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
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Affiliation(s)
- Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- The George Institute China at Peking University Health Science Center, Beijing, PR China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital & University of Copenhagen, Copenhagen, Denmark
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dariusz Gąsecki
- Department of Adult Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - Avtar Lal
- Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Lisa S Manning
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Spronk E, Sykes G, Falcione S, Munsterman D, Joy T, Kamtchum-Tatuene J, Jickling GC. Hemorrhagic Transformation in Ischemic Stroke and the Role of Inflammation. Front Neurol 2021; 12:661955. [PMID: 34054705 PMCID: PMC8160112 DOI: 10.3389/fneur.2021.661955] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/29/2021] [Indexed: 01/01/2023] Open
Abstract
Hemorrhagic transformation (HT) is a common complication in patients with acute ischemic stroke. It occurs when peripheral blood extravasates across a disrupted blood brain barrier (BBB) into the brain following ischemic stroke. Preventing HT is important as it worsens stroke outcome and increases mortality. Factors associated with increased risk of HT include stroke severity, reperfusion therapy (thrombolysis and thrombectomy), hypertension, hyperglycemia, and age. Inflammation and the immune system are important contributors to BBB disruption and HT and are associated with many of the risk factors for HT. In this review, we present the relationship of inflammation and immune activation to HT in the context of reperfusion therapy, hypertension, hyperglycemia, and age. Differences in inflammatory pathways relating to HT are discussed. The role of inflammation to stratify the risk of HT and therapies targeting the immune system to reduce the risk of HT are presented.
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Affiliation(s)
- Elena Spronk
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Gina Sykes
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sarina Falcione
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Danielle Munsterman
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Twinkle Joy
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Joseph Kamtchum-Tatuene
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Glen C Jickling
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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40
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Esmail T, Subramaniam S, Venkatraghavan L. Year in Review: Synopsis of Selected Articles in Neuroanesthesia and Neurocritical Care from 2020. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0041-1725223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractThis review is a synopsis of selected articles from neuroscience, neuroanesthesia, and neurocritical care from the year 2020 (January–December 2020). The journals reviewed include anesthesia journals, critical care medicine journals, neurology and neurosurgical journals, as well as high-impact medical journals such as the Lancet, Journal of American Medical Association, New England Journal of Medicine, and Stroke. This summary of important articles will serve to update the knowledge of anesthesiologists and other perioperative physicians who provide care to neurosurgical and neurocritical care patients. In addition, some of the important narrative reviews that are of interest to neuroanesthesiologists are also listed.
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Affiliation(s)
- Tariq Esmail
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Sudhakar Subramaniam
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Lashmi Venkatraghavan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
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41
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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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42
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Ramineni A, Roberts EA, Vora M, Mahboobi SK, Nozari A. Anesthesia Considerations in Neurological Emergencies. Neurol Clin 2021; 39:319-332. [PMID: 33896521 DOI: 10.1016/j.ncl.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Airway obstruction and respiratory failure are common complications of neurological emergencies. Anesthesia is often employed for airway management, surgical and endovascular interventions or in the intensive care units in patients with altered mental status or those requiring burst suppression. This article provides a summary of the unique airway management and anesthesia considerations and controversies for neurologic emergencies in general, as well as for specific commonly encountered conditions: elevated intracranial pressure, neuromuscular respiratory failure, acute ischemic stroke, and acute cervical spinal cord injury.
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Affiliation(s)
- Anil Ramineni
- Department of Neurology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
| | - Erik A Roberts
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
| | - Molly Vora
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
| | - Sohail K Mahboobi
- Department of Anesthesiology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Ala Nozari
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA; Department of Anesthesiology, Boston Medical Center, 750 Albany Street, Power Plant 2R, Boston, MA 02118, USA.
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43
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Anadani M, Matusevicius M, Tsivgoulis G, Peeters A, Nunes AP, Mancuso M, Roffe C, de Havenon A, Ahmed N. Magnitude of blood pressure change and clinical outcomes after thrombectomy in stroke caused by large artery occlusion. Eur J Neurol 2021; 28:1922-1930. [PMID: 33682232 DOI: 10.1111/ene.14807] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Extremes of both high and low systolic blood pressure (SBP) after mechanical thrombectomy (MT) in large artery occlusion stroke are known predictors of unfavorable outcome. However, the effect of SBP change (∆SBP) during the first 24 h on thrombectomy outcomes remains unclear. We aimed to investigate the association between ∆SBP at different time intervals and thrombectomy outcomes. METHODS We analyzed MT-treated patients registered in the SITS International Stroke Thrombectomy Registry from January 1, 2014 to September 3, 2019. Primary outcome was 3-month unfavorable outcome (modified Rankin scale scores 3-6). We defined ∆SBP as the mean SBP of a given time interval after MT (0-2, 2-4, 4-12, 12-24 h) minus admission SBP. Multivariable mixed logistic regression models were used to adjust for known confounders and center as random effect. Subgroup analyses were included to contrast specific subpopulations. Restricted cubic splines were used to model the associations. RESULTS The study population consisted of 5835 patients (mean age 70 years, 51% male, median NIHSS 16). Mean ∆SBP was -12.3, -15.7, -17.2, and -16.9 mmHg for the time intervals 0-2, 2-4, 4-12 h, and 12-24 h, respectively. Higher ∆SBP was associated with unfavorable outcome at 0-2 h (odds ratio 1.065, 95% confidence interval 1.014-1.118), 2-4 h (1.140, 1.081-1.203), 4-12 h (1.145, 1.087-1.203), and 12-24 h (1.145, 1.089-1.203), for every increase of 10 mmHg. Restricted cubic spline models suggested that increasing ∆SBP was associated with unfavorable outcome, with higher values showing increased risk of unfavorable outcome. CONCLUSION SBP increase after thrombectomy in large artery occlusion stroke is associated with poor functional outcome.
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Affiliation(s)
- Mohammad Anadani
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Marius Matusevicius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Ana Paiva Nunes
- Stroke Unit Centro Hospitalar Universitário de Lisboa Central - Hospital São José, Lisbon, Portugal
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Christine Roffe
- Stroke Research in Stoke, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurovascular Disease, Karolinska University Hospital, Stockholm, Sweden
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44
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Huang X, Guo H, Yuan L, Cai Q, Zhang M, Zhang Y, Zhu W, Li Z, Yang Q, Zhou Z, Sun W, Liu X. Blood pressure variability and outcomes after mechanical thrombectomy based on the recanalization and collateral status. Ther Adv Neurol Disord 2021; 14:1756286421997383. [PMID: 33747130 PMCID: PMC7940733 DOI: 10.1177/1756286421997383] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/29/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Blood pressure (BP), recanalization status, and collateral circulation are important factors for cerebral autoregulation after stroke. We aimed to investigate the association of various BP variability (BPV) parameters with clinical outcomes after mechanical thrombectomy (MT) according to recanalization and collateral status. METHODS We included 502 consecutive patients who underwent MT due to anterior circulation large vessel occlusion stroke at three comprehensive stroke centers. BPV parameters were standard deviation (SD), maximum/minimum BP, coefficient of variation (CV) and successive variation (SV). The clinical outcomes included 90-day functional outcome assessed by modified Rankin Scale score and symptomatic intracranial hemorrhage (sICH). RESULTS Among the included patients, 219 (43.6%) achieved good functional outcomes and 59 (11.8%) developed sICH. After adjusting for confounders, higher systolic BP (SBP) variability [CV (odds ratio (OR), 1.089, p = 0.035), SV (OR, 1.082, p = 0.004). and SD (OR, 1.074, p = 0.027)] was associated with a lower likelihood of a favorable outcome. In addition, higher SBP [CV (OR, 1.156, p = 0.001) and SD (OR, 1.118, p = 0.001)] were significantly associated with increased odds of sICH. Moreover, the relationship between BPV and the outcomes depended on recanalization status. However, regardless of collateral status, a higher BPV after MT was associated with worse outcomes. CONCLUSIONS Higher SBP SD and CV during the first 24 h after MT was a powerful predictor of worse clinical outcomes, regardless of the collateral status. However, the effects of BPV on outcomes were more substantial among patients with successful reperfusion.
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Affiliation(s)
- Xianjun Huang
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, Jiangsu Province, China
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, China
| | - Hongquan Guo
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, Jiangsu Province, China
| | - Lili Yuan
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, China
| | - Qiankun Cai
- Department of Neurology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Min Zhang
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yi Zhang
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, Jiangsu Province, China
| | - Wusheng Zhu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Zibao Li
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, China
| | - Qian Yang
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, China
| | - Wen Sun
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, 305# East Zhongshan Road, Nanjing, Jiangsu Province 210002, China
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45
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Ziai WC, Al-Kawaz M. Blood pressure management after endovascular therapy. Lancet Neurol 2021; 20:248-249. [PMID: 33647245 DOI: 10.1016/s1474-4422(21)00058-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/09/2021] [Accepted: 02/09/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Wendy C Ziai
- Department of Neurology, Division of Neurocritical Care, Johns Hopkins University, Baltimore, MD 21287, USA.
| | - Mais Al-Kawaz
- Department of Neurology, Division of Neurocritical Care, Johns Hopkins University, Baltimore, MD 21287, USA
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46
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Liu D, Nie X, Pan Y, Yan H, Pu Y, Wei Y, Cai Y, Ding Y, Lu Q, Zhang Z, Gu W, Hou X, Yang Z, Wen M, Wang P, Ma G, Ma N, Miao Z, Leng X, Yan B, Davis SM, Wang Y, Liu L. Adverse Outcomes Associated With Higher Mean Blood Pressure and Greater Blood Pressure Variability Immediately After Successful Embolectomy in Those With Acute Ischemic Stroke, and the Influence of Pretreatment Collateral Circulation Status. J Am Heart Assoc 2021; 10:e019350. [PMID: 33634704 PMCID: PMC8174261 DOI: 10.1161/jaha.120.019350] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background To investigate whether collateral status could modify the associations between post‐thrombectomy blood pressure (BP) measures and outcomes. Methods and Results Patients with anterior‐circulation large‐vessel‐occlusion successfully recanalized in a multicenter endovascular thrombectomy registry were enrolled. Pretreatment collateral status was graded and dichotomized (good/poor) in angiography. Maximum, minimum, and mean systolic BP (SBP) and BP variability (assessed by the SD, coefficient of variation) during the initial 24 hours after endovascular thrombectomy were obtained. The primary outcome was unfavorable 90‐day outcome (modified Rankin Scale score 3–6). Secondary outcomes included symptomatic intracranial hemorrhage and 90‐day mortality. Adjusted odds ratios (aOR) of BP parameters over the outcomes were obtained in all patients and in patients with good/poor collaterals. Among 596 patients (mean age 66 years; 59.9% males), 302 (50.7%) patients had unfavorable 90‐day outcome. In multivariable analyses, higher mean SBP (aOR, 1.59 per 10 mm Hg increment; 95% CI, 1.26–2.02; P<0.001), mean SBP >140 mm Hg (versus ≤120 mm Hg; aOR, 4.27; 95% CI, 1.66–10.97; P=0.002), and higher SBP SD (aOR, 1.08 per 1‐SD increment; 95% CI, 1.01–1.16; P=0.02) were respectively associated with unfavorable 90‐day outcome in patients with poor collateral but not in those with good collateral. A marginal interaction between SBP coefficient of variation tertiles and collaterals on 90‐day functional outcome (P for interaction, 0.09) was observed. A significant interaction between SBP coefficient of variation tertiles and collaterals on 90‐day mortality (P for interaction, 0.03) was observed. Conclusions Higher postprocedural BP is associated with 90‐day unfavorable outcomes after successful endovascular thrombectomy in patients with poor collateral. Registration URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1900022154.
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Affiliation(s)
- Dacheng Liu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Ximing Nie
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuesong Pan
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Hongyi Yan
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuehua Pu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yufei Wei
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuan Cai
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yarong Ding
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Qixuan Lu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Zhe Zhang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Weibin Gu
- Department of Radiology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Xinyi Hou
- Department of Radiology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Zhonghua Yang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Miao Wen
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Penglian Wang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Gaoting Ma
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Ning Ma
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Zhongrong Miao
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Prince of Wales Hospital Chinese University of Hong Kong Hong Kong SAR China
| | - Bernard Yan
- Department of Medicine and Neurology Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of Melbourne Parkville Victoria Australia
| | - Stephen M Davis
- Department of Medicine and Neurology Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of Melbourne Parkville Victoria Australia
| | - Yongjun Wang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Liping Liu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
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47
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Wu K, Xiong Z, Ding Y. Management of Elevated Blood Pressure After Stroke Thrombectomy for Anterior Circulation. Risk Manag Healthc Policy 2021; 14:405-413. [PMID: 33568958 PMCID: PMC7868952 DOI: 10.2147/rmhp.s285316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/25/2021] [Indexed: 12/11/2022] Open
Abstract
Thrombectomy is superior to intravenous thrombolysis for patients with large vessel occlusion in acute ischemic stroke, but nearly half of the patients still experience poor functional outcomes. Elevated blood pressure (BP) is widely observed in acute ischemic stroke, and BP may be one of the modifiable parameters that can potentially influence the outcomes; however, only observational studies exist to support current guidelines, and the recommended range for BP after thrombectomy is too wide to meet the clinical requirement. Randomized controlled trials are therefore needed to better understand the relationship between BP and outcomes after thrombectomy. In this review, we introduce the current management of BP after thrombectomy and several aspects of postthrombectomy BP management that should be resolved in future clinical trials.
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Affiliation(s)
- Kexin Wu
- Postgraduate School, Dalian Medical University, Dalian, People's Republic of China.,Department of Neurosurgery, Taizhou People's Hospital, Taizhou, People's Republic of China
| | - Zhencheng Xiong
- Institute of Medical Technology, Peking University Health Science Center, Beijing, People's Republic of China.,Peking University Third Hospital, Beijing, People's Republic of China
| | - Yasuo Ding
- Postgraduate School, Dalian Medical University, Dalian, People's Republic of China.,Department of Neurosurgery, Taizhou People's Hospital, Taizhou, People's Republic of China
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48
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Gigliotti MJ, Padmanaban V, Richardson A, Simon SD, Church EW, Cockroft KM. Effect of Blood Pressure Management Strategies on Outcomes in Patients with Acute Ischemic Stroke After Successful Mechanical Thrombectomy. World Neurosurg 2021; 148:e635-e642. [PMID: 33497823 DOI: 10.1016/j.wneu.2021.01.052] [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] [Received: 11/24/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Variability, with no general consensus, exists in how patients' blood pressure should be managed after successful mechanical thrombectomy (MT) for large vessel ischemic stroke. We examined whether exceeding the systolic blood pressure (SBP) targets in patients during the first 24 hours after successful MT led to worse outcomes. METHODS We retrospectively studied a consecutive sample of adult patients who had undergone MT. We collected SBP data for the first 24 hours after MT and categorized the patients into 3 groups according to cases of the SBP exceeding 140, 160, or 180 mm Hg. The primary and secondary outcomes were the modified Rankin scale score at discharge and 90 days of follow-up, the incidence of symptomatic intracranial hemorrhage, malignant cerebral edema, and hemicraniectomy, mortality within 90 days, and discharge disposition. RESULTS A total of 117 patients were included (mean age, 65 ± 13.12 years; 53% female). The occurrence of ≥1 instance of SBP ≥180 mm Hg was significantly associated with poor functional outcomes at discharge (adjusted odds ratio [OR], 5.83; 95% confidence interval [CI], 1.41-32.9; P = 0.025) but not at 90 days of follow-up. The occurrence of SBP ≥160 mm Hg resulted in an independently increased odds of malignant cerebral edema (adjusted OR, 17.07; 95% CI, 2.56-174.4; P = 0.01), with a trend toward increased odds of symptomatic intracranial hemorrhage (adjusted OR, 4.42; 95% CI, 1.03-21.2; P = 0.0503). CONCLUSIONS These results suggest that individual instances of SBP elevation alone after successful MT, rather than a necessarily prolonged increased blood pressure as reflected by the mean or median SBP values, can significantly affect the clinical outcomes after successful MT.
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Affiliation(s)
- Michael J Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Varun Padmanaban
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Alicia Richardson
- Penn State Hershey Comprehensive Stroke Center, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Scott D Simon
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Ephraim W Church
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Penn State Hershey Comprehensive Stroke Center, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
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49
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Maïer B, Desilles JP, Mazighi M. Intracranial Hemorrhage After Reperfusion Therapies in Acute Ischemic Stroke Patients. Front Neurol 2020; 11:599908. [PMID: 33362701 PMCID: PMC7759548 DOI: 10.3389/fneur.2020.599908] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
Reperfusion therapies are the mainstay of acute ischemic stroke (AIS) treatments and overall improve functional outcome. Among the established complications of intravenous (IV) tissue-type plasminogen activator (tPA), intracranial hemorrhage (ICH) is by far the most feared and has been extensively described by seminal works over the last two decades. Indeed, IV tPA is associated with increased odds of any ICH and symptomatic ICH responsible for increased mortality rate during the first week after an AIS. Despite these results, IV tPA has been found beneficial in several pioneering randomized trials and improves functional outcome at 3 months. Endovascular therapy (EVT) combined with IV tPA for AIS patients consecutive to an anterior circulation large-vessel occlusion does not increase ICH occurrence. Of note, EVT following IV tPA leads to significantly higher rates of early reperfusion than with IV tPA alone, with no difference in ICH, which challenges the paradigm of reperfusion as a major prognostic factor for ICH complications. However, several blood biomarkers (glycemia, platelet and neutrophil count), clinical factors (age, AIS severity, blood pressure management, diabetes mellitus), and neuroradiological factors (cerebral microbleeds, infarct size) have been identified as risk factors for ICH after reperfusion therapy. In the years to come, the ultimate goal will be to further improve either reperfusion rates and functional outcome, while reducing hemorrhagic complications. To this end, various approaches being investigated are discussed in this review, such as blood-pressure control after reperfusion or the use of new antiplatelet agents as an adjunct to IV tPA and exhibit reduced hemorrhagic potential during the early phase of AIS.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Jean Philippe Desilles
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
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50
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Jafari M, Desai A, Damani R. Blood pressure management after mechanical thrombectomy in stroke patients. J Neurol Sci 2020; 418:117140. [PMID: 32961389 DOI: 10.1016/j.jns.2020.117140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/15/2022]
Abstract
Endovascular treatment of acute ischemic stroke (AIS) and mechanical thrombectomy (MT) is proven as a safe and effective novel treatment for emergent large vessel occlusion in the anterior cerebral circulation. However, there are still many unanswered questions on peri and post-procedural management including blood pressure (BP) control. The current guidelines recommend maintaining BP <180/105 mmHg in the first 24 h after MT. However, recent studies suggest that maintaining BP levels at lower levels in the first 24 h after successful revascularization have been associated with favorable functional outcome, reduced mortality rate, and hemorrhagic complications. Not only absolute BP but also its variation in the first 24 h after MT have been associated with neurological outcomes. Evidence on the effect of BP variability (BPV) after MT in AIS even though limited, it does indicate the association of the higher BPV in the first 24 h after MT and poor functional outcomes in AIS. In this review, we will discuss the current literature on BP management in the first 24 h after MT and the impact of BPV in the first 24 h after MT.
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Affiliation(s)
- Mostafa Jafari
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Aaron Desai
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Rahul Damani
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
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