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Robbe MMQ, Pinckaers FME, Olthuis SGH, Bos MJ, van Oostenbrugge RJ, van Zwam WH, Staals J, Postma AA. Procedural Blood Pressure and Intracranial Hemorrhage on Dual-Energy Computed Tomography After Endovascular Stroke Treatment. Cardiovasc Intervent Radiol 2024; 47:483-491. [PMID: 38062172 DOI: 10.1007/s00270-023-03619-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/06/2023] [Indexed: 04/07/2024]
Abstract
PURPOSE Optimal systolic blood pressure (SBP) management during endovascular treatment (EVT) for acute ischemic stroke remains a topic of debate. Though BP is associated with worse functional outcome, the relationship between BP and post-procedural intracranial hemorrhage (ICH) is less well-known. We aimed to investigate the association between BP during EVT and post-procedural ICH on dual-energy CT (DECT). METHODS We included all patients who underwent EVT for an anterior circulation large vessel occlusion between 2010 and 2019, and received DECT < 3 h post-EVT. All BP measurements during the EVT procedure were used to calculate mean arterial pressure (MAPmean), mean SBP (SBPmean), and SBPmax-min (highest minus lowest). ICH was assessed using virtual post-procedural unenhanced DECT reconstructions and classified as intraparenchymal or extraparenchymal. Symptomatic ICH was scored according to the Heidelberg criteria. The association between different BP parameters and ICH was assessed using multivariable logistic regression. RESULTS We included 478 patients. Seventy-six patients (16%) demonstrated ICH on DECT, of which 26 (34%) were intraparenchymal. Symptomatic intraparenchymal and extraparenchymal ICH occurred in 10 (38%) and 4 (8%) patients. SBPmax, SBPmean, and MAPmean were associated with intraparenchymal ICH with an adjusted odds ratio of 1.19 (95%CI, 1.02-1.39), 1.22 (95%CI, 1.03-1.46), and 1.40 (95%CI, 1.09-1.81) per 10 mmHg, while BP was not significantly associated with extraparenchymal ICH. BP did not differ between asymptomatic and symptomatic ICH. CONCLUSION Procedural BP is associated with intraparenchymal ICH on post-EVT DECT but not with extraparenchymal ICH. Future studies should evaluate whether individual procedural BP management reduces post-EVT ICH and improves clinical outcome.
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Affiliation(s)
- M M Q Robbe
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands.
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - F M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - S G H Olthuis
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M J Bos
- Departments of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - W H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J Staals
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands
- School for Mental Health and Sciences (MHENS), Maastricht University, Maastricht, The Netherlands
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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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Kappel AD, Nguyen HB, Frerichs KU, Patel NJ, Aziz-Sultan MA, Du R. Randomized Clinical Trials in Cerebrovascular Neurosurgery From 2018 to 2022. Cureus 2024; 16:e52397. [PMID: 38361699 PMCID: PMC10869144 DOI: 10.7759/cureus.52397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
There has been an exponential increase in randomized controlled trials (RCTs) on cerebrovascular disease within neurosurgery. The goal of this study was to review, outline the scope, and summarize all phase 2b and phase 3 RCTs impacting cerebrovascular neurosurgery practice since 2018. We searched PubMed, MEDLINE, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases for relevant RCTs published between January 1, 2018, and July 1, 2022. We searched for studies related to eight major cerebrovascular disorders relevant to neurosurgery, including acute ischemic stroke, cerebral aneurysms and subarachnoid hemorrhage, intracerebral hemorrhage, subdural hematomas, cerebral venous thrombosis, arteriovenous malformations, Moyamoya disease and extracranial-intracranial bypass, and carotid and intracranial atherosclerosis. We limited our search to phase 2b or 3 RCTs related to cerebrovascular disorders published during the study period. The titles and abstracts of all relevant studies meeting our search criteria were included. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. From an initial total of 2,797 records retrieved from the database searches, 1,641 records were screened after duplicates and studies outside of our time period were removed. After screening, 511 available reports within our time period of interest were assessed for eligibility. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. We found 80 unique phase 2b or 3 RCTs that fit our criteria, with 165 topic-relevant articles published within the study period. Numerous RCTs in cerebrovascular neurosurgery have been published since 2018. Ischemic stroke, including mechanical thrombectomy and thrombolysis, accounted for a majority of publications, but there were large trials in intracerebral hemorrhage, subdural hemorrhage, aneurysms, subarachnoid hemorrhage, and cerebral venous thrombosis, among others. This review helps define the scope of the large RCTs published in the last four years to guide future research and clinical care.
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Affiliation(s)
- Ari D Kappel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | | | - Nirav J Patel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | - Rose Du
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
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Chen M, Meis J, Potreck A, Sauer LD, Kieser M, Bendszus M, Wick W, Ringleb PA, Möhlenbruch MA, Schönenberger S. Effect of Individualized Versus Standardized Blood Pressure Management During Endovascular Stroke Treatment on Clinical Outcome: A Randomized Clinical Trial. Stroke 2023; 54:2755-2765. [PMID: 37732489 DOI: 10.1161/strokeaha.123.044062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Optimal blood pressure (BP) management during endovascular stroke treatment is not well established. We studied whether an individualized approach for managing BP during endovascular stroke treatment gives a better clinical outcome than an approach with standardized systolic BP targets. METHODS The INDIVIDUATE study (Individualized Blood Pressure Management During Endovascular Treatment of Acute Ischemic Stroke Under Procedural Sedation) is a randomized clinical trial with a prospective randomized open blinded end point (PROBE) design. Patients were recruited between October 1, 2020 and July 7, 2022 at a single center at a tertiary care university hospital. Patients were eligible, when they were suffering from acute ischemic stroke of the anterior circulation with occlusions of the internal carotid artery and middle cerebral artery and a National Institutes of Health Stroke Scale score of ≥8 receiving endovascular stroke treatment in procedural sedation. The intervention consists of an individualized BP management strategy, where preinterventional baseline systolic BP (SBP) values are used as intraprocedural BP targets. As a control, the standard treatment aims to maintain the intraprocedural SBP between 140 and 180 mm Hg. The main prespecified outcome is the proportion of favorable functional outcomes 90 days after stroke, defined as a modified Rankin Scale score of 0 to 2. RESULTS Two hundred fifty patients were enrolled and included in the analysis, mean (SD) age was 77 (12) years, 142 (57%) patients were women, and mean (SD) National Institutes of Health Stroke Scale score on admission was 17 (5.2). In all, 123 (49%) patients were treated with individualized and 127 (51%) with standard BP management. Mean (SD) intraprocedural SBP was similar in the individualized versus standard BP management group (157 [19] versus 154 [18] mm Hg; P=0.16). The rate of favorable functional outcome after 3 months was not significantly different between the individualized versus the standard BP management group (25% versus 24%; adjusted odds ratio, 0.81 [95% CI, 0.41-1.61]; P=0.56). CONCLUSIONS Among patients treated with endovascular stroke treatment due to an acute ischemic stroke of the anterior circulation, no significant difference was seen between the individualized BP management strategy, where intraprocedural SBP was targeted to baseline values, and the standardized regimen of targeting SBP between 140 and 180 mm Hg. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04578288.
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Affiliation(s)
- Min Chen
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Arne Potreck
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Lukas D Sauer
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Meinhard Kieser
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Martin Bendszus
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Wolfgang Wick
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Peter A Ringleb
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Silvia Schönenberger
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
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Chen C, Ouyang M, Ong S, Zhang L, Zhang G, Delcourt C, Mair G, Liu L, Billot L, Li Q, Chen X, Parsons M, Broderick JP, Demchuk AM, Bath PM, Donnan GA, Levi C, Chalmers J, Lindley RI, Martins SO, Pontes-Neto OM, Venturelli PM, Olavarría V, Lavados P, Robinson TG, Wardlaw JM, Li G, Wang X, Song L, Anderson CS. Effects of intensive blood pressure lowering on cerebral ischaemia in thrombolysed patients: insights from the ENCHANTED trial. EClinicalMedicine 2023; 57:101849. [PMID: 36820100 PMCID: PMC9938155 DOI: 10.1016/j.eclinm.2023.101849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 02/17/2023] Open
Abstract
Background Intensive blood pressure lowering may adversely affect evolving cerebral ischaemia. We aimed to determine whether intensive blood pressure lowering altered the size of cerebral infarction in the 2196 patients who participated in the Enhanced Control of Hypertension and Thrombolysis Stroke Study, an international randomised controlled trial of intensive (systolic target 130-140 mm Hg within 1 h; maintained for 72 h) or guideline-recommended (systolic target <180 mm Hg) blood pressure management in patients with hypertension (systolic blood pressure >150 mm Hg) after thrombolysis treatment for acute ischaemic stroke between March 3, 2012 and April 30, 2018. Methods All available brain imaging were analysed centrally by expert readers. Log-linear regression was used to determine the effects of intensive blood pressure lowering on the size of cerebral infarction, with adjustment for potential confounders. The primary analysis pertained to follow-up computerised tomography (CT) scans done between 24 and 36 h. Sensitivity analysis were undertaken in patients with only a follow-up magnetic resonance imaging (MRI) and either MRI or CT at 24-36 h, and in patients with any brain imaging done at any time during follow-up. This trial is registered with ClinicalTrials.gov, number NCT01422616. Findings There were 1477 (67.3%) patients (mean age 67.7 [12.1] y; male 60%, Asian 65%) with available follow-up brain imaging for analysis, including 635 patients with a CT done at 24-36 h. Mean achieved systolic blood pressures over 1-24 h were 141 mm Hg and 149 mm Hg in the intensive group and guideline group, respectively. There was no effect of intensive blood pressure lowering on the median size (ml) of cerebral infarction on follow-up CT at 24-36 h (0.3 [IQR 0.0-16.6] in the intensive group and 0.9 [0.0-12.5] in the guideline group; log Δmean -0.17, 95% CI -0.78 to 0.43). The results were consistent in sensitivity and subgroup analyses. Interpretation Intensive blood pressure lowering treatment to a systolic target <140 mm Hg within several hours after the onset of symptoms may not increase the size of cerebral infarction in patients who receive thrombolysis treatment for acute ischaemic stroke of mild to moderate neurological severity. Funding National Health and Medical Research Council of Australia; UK Stroke Association; UK Dementia Research Institute; Ministry of Health and the National Council for Scientific and Technological Development of Brazil; Ministry for Health, Welfare, and Family Affairs of South Korea; Takeda.
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Affiliation(s)
- Chen Chen
- Neurology Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Menglu Ouyang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Sheila Ong
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Luyun Zhang
- The George Institute for Global Health China, Beijing, China
- Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, Shenyang, China
| | - Guobin Zhang
- The George Institute for Global Health China, Beijing, China
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Grant Mair
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences and Centre in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Leibo Liu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Xiaoying Chen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Mark Parsons
- Ingham Institute for Applied Medical Research, Liverpool Hospital, UNSW, Sydney, Australia
| | - Joseph P. Broderick
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Andrew M. Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Geoffrey A. Donnan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Christopher Levi
- Neurology Department, John Hunter Hospital, and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Richard I. Lindley
- University of Sydney, Sydney, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Sheila O. Martins
- Stroke Division of Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Octavio M. Pontes-Neto
- Stroke Service - Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of Sao Paulo, Ribeirão Preto, SP, Brazil
| | - Paula Muñoz Venturelli
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Centro de Estudios Clínicos, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Verónica Olavarría
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Pablo Lavados
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Thompson G. Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences and Centre in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Gang Li
- Neurology Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xia Wang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lili Song
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Craig S. Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
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Ping Z, Min L, Qiuyun L, Xu C, Qingke B. Prognostic nomogram for the outcomes in acute stroke patients with intravenous thrombolysis. Front Neurosci 2022; 16:1017883. [PMID: 36340757 PMCID: PMC9627298 DOI: 10.3389/fnins.2022.1017883] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/20/2022] [Indexed: 11/25/2022] Open
Abstract
Background and purpose The prediction of neurological outcomes in ischemic stroke patients is very useful in treatment choices, as well as in post-stroke management. This study is to develop a convenient nomogram for the bedside evaluation of stroke patients with intravenous thrombolysis. Materials and methods We reviewed all enrolled stroke patients with intravenous thrombolysis retrospectively. Favorable outcome was defined as modified Rankin Score (mRs) less than 2 at 90 days post thrombolysis. We compared the clinical characteristics between patients with favorable outcome and poor outcome. Then, we applied logistic regression models and compared their predictability. Results A total of 918 patients were enrolled in this study, 448 patients from one hospital were included to develop a nomogram, whereas 470 patients from the other hospital were used for the external validation. Associated risk factors were identified by multivariate logistic regression. The nomogram was validated by the area under the receiver operating characteristic curve (AUC). A nomogram was developed with baseline NIHSS, blood sugar, blood cholesterol level, part-and full anterior circulation infarction (OCSP type). The AUC was 0.767 (95% CI 0.653–0.772) and 0.836 (95% CI 0.697–0.847) in the derivation and external validation cohorts, respectively. The calibration plot for the probability of severe neurological outcome showed an optimal agreement between the prediction by nomogram and actual observation in both derivation and validation cohorts. Conclusion A convenient outcome evaluation nomogram for patients with intravenous thrombolysis was developed, which could be used by physicians in making clinical decisions and predicting patients’ prognosis.
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Affiliation(s)
- Zheng Ping
- Key Laboratory and Neurosurgery, Shanghai Pudong New Area People’s Hospital, Shanghai, China
- *Correspondence: Zheng Ping, ; orcid.org/0000-0002-3928-3875
| | - Li Min
- Department of Neurology, Shanghai Pudong New Area People’s Hospital, Shanghai, China
| | - Lu Qiuyun
- Department of Neurology, Shanghai Eighth People’s Hospital, Shanghai, China
| | - Chen Xu
- Department of Neurology, Shanghai Eighth People’s Hospital, Shanghai, China
| | - Bai Qingke
- Department of Neurology, Shanghai Pudong New Area People’s Hospital, Shanghai, China
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Michalski D, Jungk C, Brenner T, Nusshag C, Reuß CJ, Fiedler MO, Schmitt FCF, Bernhard M, Beynon C, Weigand MA, Dietrich M. Fokus Neurologische Intensivmedizin 2021/2022. DIE ANAESTHESIOLOGIE 2022; 71:872-881. [PMID: 36125510 PMCID: PMC9486788 DOI: 10.1007/s00101-022-01196-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - F C F Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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8
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Stolp J, Coutinho JM, Immink RV, Preckel B. Anesthetic considerations for endovascular treatment in stroke therapy. Curr Opin Anaesthesiol 2022; 35:472-478. [PMID: 35787587 DOI: 10.1097/aco.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The introduction of clot removement by endovascular treatment (EVT) in 2015 has improved the clinical outcome of patients with acute ischemic stroke (AIS) due to a large vessel occlusion (LVO). Anesthetic strategies during EVT vary widely between hospitals, with some departments employing local anesthesia (LA), others performing conscious sedation (CS) or general anesthesia (GA). The optimal anesthetic strategy remains debated. This review will describe the effects of anesthetic strategy on clinical and radiological outcomes and hemodynamic parameters in patients with AIS undergoing EVT. RECENT FINDINGS Small single-center randomized controlled trails (RCTs) found either no difference or favored GA, while large observational cohort studies favored CS or LA. RCTs using LA as separate comparator arm are still lacking and a meta-analysis of observational studies failed to show differences in functional outcome between LA vs. other anesthetic strategies. Advantages of LA were shorter door-to-groin time in patients and less intraprocedural hypotension, which are both variables that are known to impact functional outcome. SUMMARY The optimal anesthetic approach in patients undergoing EVT for stroke therapy is still unclear, but based on logistics and peri-procedural hemodynamics, LA may be the optimal choice. Multicenter RCTs are warranted comparing LA, CS and GS with strict blood pressure targets and use of the same anesthetic agents to minimize confounding variables.
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Affiliation(s)
| | | | - Rogier V Immink
- Department of Anesthesiology, Amsterdam UMC Location AMC, University of Amsterdam
| | - Benedikt Preckel
- Department of Anesthesiology, Amsterdam UMC Location AMC, University of Amsterdam
- Amsterdam Public Health, Quality of Care
- Amsterdam Cardiovascular Science, Diabetes & Metabolism, Amsterdam, The Netherlands
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9
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Maïer B, Gory B, Chabanne R, Tavernier B, Balanca B, Audibert G, Thion LA, Le Guen M, Geeraerts T, Calviere L, Degos V, Lapergue B, Richard S, Djarallah A, Mophawe O, Boursin P, Le Cossec C, Blanc R, Piotin M, Mazighi M, Gayat E. Effect of an individualized versus standard blood pressure management during mechanical thrombectomy for anterior ischemic stroke: the DETERMINE randomized controlled trial. Trials 2022; 23:598. [PMID: 35883180 PMCID: PMC9317065 DOI: 10.1186/s13063-022-06538-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hypotension and blood pressure (BP) variability during endovascular therapy (EVT) for acute ischemic stroke (AIS) due to an anterior large vessel occlusion (LVO) is associated with worse outcomes. However, the optimal BP threshold during EVT is still unknown given the lack of randomized controlled evidence. We designed the DETERMINE trial to assess whether an individualized BP management during EVT could achieve better functional outcomes compared to a standard BP management. Methods The DETERMINE trial is a multicenter, prospective, randomized, controlled, open-label, blinded endpoint clinical trial (PROBE design). AIS patients with a proximal anterior LVO are randomly assigned, in a 1:1 ratio, to an experimental arm in which mean arterial pressure (MAP) is maintained within 10% of the first MAP measured before EVT, or a control arm in which systolic BP (SBP) is maintained within 140–180 mm Hg until reperfusion is achieved or artery closure in case of EVT failure. The primary outcome is the rate of favorable functional outcomes, defined by a modified Rankin Scale (mRS) between 0 and 2 at 90 days. Secondary outcomes include excellent outcome and ordinal analysis of the mRS at 90 days, early neurological improvement at 24 h (National Institutes of Health Stroke Scale), final infarct volume, symptomatic intracranial hemorrhage rates, and all-cause mortality at 90 days. Overall, 432 patients will be included. Discussion DETERMINE will assess the clinical relevance of an individualized BP management before reperfusion compared to the one size fits all approach currently recommended by international guidelines. Trial registration ClinicalTrials.gov, NCT04352296. Registered on 20th April 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06538-9.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France. .,Université Paris-Cité, Paris, France.
| | - Benjamin Gory
- Diagnostic and Therapeutic Neuroradiology Department, CHRU-Nancy, Université de Lorraine, INSERM U124, Nancy, France
| | - Russell Chabanne
- Department of Anesthesia, Critical Care and Peri-Operative Medicine, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Benoît Tavernier
- Department of Anesthesia and Critical Care, University Hospital, Lille, F-59000, Lille, France.,Université Lille, ULR 2694 - METRICS, F-59000, Lille, France
| | - Baptiste Balanca
- Department of Neurological Anesthesiology and Intensive Care, Hospices Civils de Lyon, Hôpital Pierre Wertheimer, Groupement Hospitalier Est, 59 Boulevard Pinel, 69500, Bron, Lyon, France.,Lyon's Neuroscience Research Center, INSERM U1028/CNRS UMR 5292, Lyon 1 University, Lyon, France
| | | | - Laurie-Anne Thion
- Anesthesiology Department, Hôpital fondation A. de Rothschild, Paris, France
| | - Morgan Le Guen
- Anesthesiology Department, Foch Hospital, Suresnes, France
| | - Thomas Geeraerts
- Anesthesiology and Critical Care department, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Lionel Calviere
- Neurology Department, University Hospital of Toulouse, Toulouse, France
| | - Vincent Degos
- Department of Anesthesia, Critical Care and Peri-Operative Medicine, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France.,INSERM UMR 1141, Paris, France
| | | | - Sebastien Richard
- Neurology Department, CHRU-Nancy, Université de Lorraine, Nancy, France
| | - Azeddine Djarallah
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Ornellia Mophawe
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Perrine Boursin
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Chloé Le Cossec
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Raphael Blanc
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France.,Université Paris-Cité, Paris, France
| | - Etienne Gayat
- Université Paris-Cité, Paris, France.,Anesthesiology Department, Hôpital Lariboisière, Paris, France
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