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Tao M, Li Y, Peng Y, Zhang X, Liu S, Tang T, Xu T, Ke K. Blood Pressure Fluctuation During 72 Hours After Endovascular Therapy and Prognosis in Acute Ischemic Stroke Patients. J Endovasc Ther 2024:15266028241266235. [PMID: 39058276 DOI: 10.1177/15266028241266235] [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: 07/28/2024]
Abstract
PURPOSE Our study aimed to investigate the relationship between fluctuations in different blood pressure (BP) components within 72 hours following endovascular therapy (EVT) and the prognosis of acute ischemic stroke (AIS) patients. METHODS This prospective multicenter study included 283 AIS patients who underwent EVT and had available BP data. The primary outcome was the ordinal modified Rankin Scale (mRS) score evaluated at 90 days. The secondary outcome was a combination of death and major disability, defined as an mRS score of 3 to 6 within 3 months. RESULTS After adjusting for imbalanced variables, the highest tertile of systolic blood pressure (SBP) fluctuation had an odds ratio (OR) of 1.747 (95% confidence interval [CI]=1.031-2.961; p for trend=0.035) for the primary outcome and 1.889 (95% CI=1.015-3.516; p for trend=0.039) for the secondary outcome, respectively. Fluctuations in diastolic blood pressure (DBP) (OR=1.914, 95% CI=1.134-3.230, p for trend=0.015) and mean arterial pressure (MAP) (OR=1.759, 95% CI=1.026-3.015, p for trend=0.039) were only associated with the primary outcome. The multivariate-adjusted restricted cubic spline analyses supported these findings. Furthermore, the fluctuations in both SBP and MAP exhibited the significant discriminatory capability in predicting the prognosis, comparable to their mean values. CONCLUSION Our study revealed that larger fluctuations in SBP, DBP, and MAP within 72 hours after EVT were associated with a higher risk of poor clinical outcomes within 3 months in AIS patients. Controlling BP fluctuations may be valuable for improving the prognosis in patients undergoing EVT. CLINICAL IMPACT How will this change clinical practice?It provides physicians a new approach to directly monitor BP fluctuations over an extended observation period in AIS patients after EVT in routine clinical practice.What does it mean for the clinicians?These results underscore the importance of giving equal attention to controlling long-term BP fluctuations, in addition to managing mean BP, as a means to improve the prognosis of AIS patients after EVT.What is the innovation behind the study?This study systematically evaluated the association between fluctuations in different blood pressure components and clinical outcomes in AIS patients over an extended period following EVT.
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Affiliation(s)
- Mingfeng Tao
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Yongxin Li
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Ya Peng
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xin Zhang
- Department of Neurology, Nanjing Drum Tower Hospital, Nanjing, China
| | - Sheng Liu
- Department of Radiology, Jiangsu Provincial People's Hospital, Nanjing Medical University, Nanjing, China
| | - Tieyu Tang
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Tian Xu
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Kaifu Ke
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
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Leslie-Mazwi TM. Neurocritical Care for Patients With Ischemic Stroke. Continuum (Minneap Minn) 2024; 30:611-640. [PMID: 38830065 DOI: 10.1212/con.0000000000001427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Management of stroke due to large vessel occlusion (LVO) has undergone unprecedented change in the past decade. Effective treatment with thrombectomy has galvanized the field and led to advancements in all aspects of care. This article provides a comprehensive examination of neurologic intensive care unit (ICU) management of patients with stroke due to LVO. The role of the neurocritical care team in stroke systems of care and the importance of prompt diagnosis, initiation of treatment, and continued monitoring of patients with stroke due to LVO is highlighted. LATEST DEVELOPMENTS The management of complications commonly associated with stroke due to LVO, including malignant cerebral edema and respiratory failure, are addressed, stressing the importance of early identification and aggressive treatment in mitigating negative effects on patients' prognoses. In the realm of medical management, this article discusses various medical therapies, including antithrombotic therapy, blood pressure management, and glucose control, outlining evidence-based strategies for optimizing patient outcomes. It further emphasizes the importance of a multidisciplinary approach to provide a comprehensive care model. Lastly, the critical aspect of family communication and prognostication in the neurologic ICU is addressed. ESSENTIAL POINTS This article emphasizes the multidimensional aspects of neurocritical care in treating patients with stroke due to LVO.
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Katsanos AH, Joundi R, 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 N, Tsivgoulis G. Blood Pressure Trajectories and Outcomes After Endovascular Thrombectomy for Acute Ischemic Stroke. Hypertension 2024; 81:629-635. [PMID: 38164751 PMCID: PMC11289690 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
- Department of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Raed Joundi
- Department of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - 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, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, 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, Utah, 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
| | - 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, Tennessee, USA
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam S. Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Amrou Sarraj
- Department of Neurology, Case Western Reserve University, University Hospitals Cleveland Medical Center, OH
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY
| | - Ashkan Shoamanesh
- Department of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Luciana Catanese
- Department of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Konstantinos Tsioufis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Greece
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Alejandro M. Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Andrei V. Alexandrov
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Nils Petersen
- Department of Neurology, Yale University, New Haven, 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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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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5
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Nam HS, Kim YD, Heo J, Lee H, Jung JW, Choi JK, Lee IH, Lim IH, Hong SH, Baik M, Kim BM, Kim DJ, Shin NY, Cho BH, Ahn SH, Park H, Sohn SI, Hong JH, Song TJ, Chang Y, Kim GS, Seo KD, Lee K, Chang JY, Seo JH, Lee S, Baek JH, Cho HJ, Shin DH, Kim J, Yoo J, Lee KY, Jung YH, Hwang YH, Kim CK, Kim JG, Lee CJ, Park S, Lee HS, Kwon SU, Bang OY, Anderson CS, Heo JH. Intensive vs Conventional Blood Pressure Lowering After Endovascular Thrombectomy in Acute Ischemic Stroke: The OPTIMAL-BP Randomized Clinical Trial. JAMA 2023; 330:832-842. [PMID: 37668619 PMCID: PMC10481233 DOI: 10.1001/jama.2023.14590] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/22/2023] [Indexed: 09/06/2023]
Abstract
Importance Optimal blood pressure (BP) control after successful reperfusion with endovascular thrombectomy (EVT) for patients with acute ischemic stroke is unclear. Objective To determine whether intensive BP management during the first 24 hours after successful reperfusion leads to better clinical outcomes than conventional BP management in patients who underwent EVT. Design, Setting, and Participants Multicenter, randomized, open-label trial with a blinded end-point evaluation, conducted across 19 stroke centers in South Korea from June 2020 to November 2022 (final follow-up, March 8, 2023). It included 306 patients with large vessel occlusion acute ischemic stroke treated with EVT and with a modified Thrombolysis in Cerebral Infarction score of 2b or greater (partial or complete reperfusion). Interventions Participants were randomly assigned to receive intensive BP management (systolic BP target <140 mm Hg; n = 155) or conventional management (systolic BP target 140-180 mm Hg; n = 150) for 24 hours after enrollment. Main Outcomes and Measures The primary outcome was functional independence at 3 months (modified Rankin Scale score of 0-2). The primary safety outcomes were symptomatic intracerebral hemorrhage within 36 hours and death related to the index stroke within 3 months. Results The trial was terminated early based on the recommendation of the data and safety monitoring board, which noted safety concerns. Among 306 randomized patients, 305 were confirmed eligible and 302 (99.0%) completed the trial (mean age, 73.0 years; 122 women [40.4%]). The intensive management group had a lower proportion achieving functional independence (39.4%) than the conventional management group (54.4%), with a significant risk difference (-15.1% [95% CI, -26.2% to -3.9%]) and adjusted odds ratio (0.56 [95% CI, 0.33-0.96]; P = .03). Rates of symptomatic intracerebral hemorrhage were 9.0% in the intensive group and 8.1% in the conventional group (risk difference, 1.0% [95% CI, -5.3% to 7.3%]; adjusted odds ratio, 1.10 [95% CI, 0.48-2.53]; P = .82). Death related to the index stroke within 3 months occurred in 7.7% of the intensive group and 5.4% of the conventional group (risk difference, 2.3% [95% CI, -3.3% to 7.9%]; adjusted odds ratio, 1.73 [95% CI, 0.61-4.92]; P = .31). Conclusions and Relevance Among patients who achieved successful reperfusion with EVT for acute ischemic stroke with large vessel occlusion, intensive BP management for 24 hours led to a lower likelihood of functional independence at 3 months compared with conventional BP management. These results suggest that intensive BP management should be avoided after successful EVT in acute ischemic stroke. Trial Registration ClinicalTrials.gov Identifier: NCT04205305.
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Affiliation(s)
- Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyungwoo Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Il Hyung Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - In Hwan Lim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Soon-Ho Hong
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Minyoul Baik
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Na-Young Shin
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Bang-Hoon Cho
- Department of Neurology, Korea University Anam Hospital and College of Medicine, Seoul, Korea
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University School of Medicine, Gwangju, Korea
| | - Hyungjong Park
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Yoonkyung Chang
- Department of Neurology, Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Gyu Sik Kim
- Department of Neurology, National Health Insurance Service, Ilsan Hospital, Goyang, Korea
| | - Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service, Ilsan Hospital, Goyang, Korea
| | - Kijeong Lee
- Department of Neurology, National Health Insurance Service, Ilsan Hospital, Goyang, Korea
| | - Jun Young Chang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Hwa Seo
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Sukyoon Lee
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Han-Jin Cho
- Department of Neurology, Pusan National University School of Medicine, Busan, Korea
| | - Dong Hoon Shin
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea
| | - Jinkwon Kim
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yo Han Jung
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital and College of Medicine, Seoul, Korea
| | - Jae Guk Kim
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Chan Joo Lee
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sungha Park
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Division of Cardiology, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Sun U. Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Craig S. Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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Association of 24-hour blood pressure parameters post-thrombectomy with functional outcomes according to collateral status. J Neurol Sci 2022; 441:120369. [DOI: 10.1016/j.jns.2022.120369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/07/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022]
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Vilionskis A, Gaigalaite V, Salasevicius L, Jatuzis D. Association between systolic blood pressure parameters and unexplained early neurological deterioration (UnND) in acute ischemic stroke patients treated with mechanical thrombectomy. Ther Adv Neurol Disord 2022; 15:17562864221093524. [PMID: 35747319 PMCID: PMC9210098 DOI: 10.1177/17562864221093524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Neurological deterioration (ND) after mechanical thrombectomy (MT) of acute ischemic stroke (AIS) in anterior circulation is an important complication associated with a poor outcome. Moreover, evident causes of ND may remain unexplained (UnND). Objective: We sought to evaluate the association of the systolic blood pressure (SBP) parameters before MT, during MT, and during a 24-h period after MT with UnND. Methods: We analyzed 382 MT-treated AIS patients in two stroke centers from 2017 to 2019. The patients with unsuccessful recanalization and/or with symptomatic intracerebral hemorrhage after MT were excluded. Multivariate logistic regression analysis was used to identify the SBP parameters that predict UnND. Results: There were 5.9% patients with UnND within 24 h after MT among patients with successful recanalization what comprises 4.9% of all patients who had undergone MT. SBP > 180 mmHg on admission (odds ratio (OR): 4, 95% confidence interval (CI): 1.6–10, p = 0.004) and a drop of SBP below100 mmHg during MT (OR: 4.7, 95% CI: 1.3–17, p = 0.019) were associated with UnND occurrence within 7 days without a significant association with UnND within 24 h. UnND within 7 days was predicted by the episodes of SBP exceeding the level of SBP observed before the groin puncture and occurring over the first 2 h following recanalization (OR: 5, 95% CI: 1.3–19, p = 0.021), an increase of SBP of more than 20% within 2–24 h after MT (OR: 3.4, 95% CI: 1.1–10, p = 0.035), and a drop of SBP below 100 mmHg after MT (OR: 3.2, 95% CI: 1.1–9, p = 0.039). Conclusion: The association between the SBP parameters and UnND depends on the treatment period and the time of UnND occurrence. The J/U resembling relationship between SBP and UnEND was established during a 24-h period after MT.
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Affiliation(s)
| | - Virginija Gaigalaite
- Institute of Clinical Medicine, Vilnius University, Siltnamiu 29, Vilnius 01513, Lithuania
| | | | - Dalius Jatuzis
- Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
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8
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Petersen NH, Kodali S, Meng C, Li F, Nguyen CK, Peshwe KU, Strander S, Silverman A, Kimmel A, Wang A, Anadani M, Almallouhi E, Spiotta AM, Kim JT, Giles JA, Keyrouz SG, Farooqui M, Zevallos C, Maier IL, Psychogios MN, Liman J, Riou-Comte N, Richard S, Gory B, Quintero Wolfe S, Brown PA, Fargen KM, Mistry EA, Fakhri H, Mistry AM, Wong KH, de Havenon A, Nascimento FA, Kan P, Matouk C, Ortega-Gutiérrez S, Sheth KN. Blood Pressure Trajectory Groups and Outcome After Endovascular Thrombectomy: A Multicenter Study. Stroke 2022; 53:1216-1225. [PMID: 34781705 PMCID: PMC8960326 DOI: 10.1161/strokeaha.121.034408] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 08/10/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes. METHODS This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the modified Rankin Scale 90 days after stroke. Secondary outcomes included hemorrhagic transformation, symptomatic intracranial hemorrhage, and death. RESULTS Two thousand two hundred sixty-eight patients (mean age [±SD] 69±15, mean National Institutes of Health Stroke Scale 15±7) were included in the analysis. Five distinct SBP trajectories were observed: low (18%), moderate (37%), moderate-to-high (20%), high-to-moderate (18%), and high (6%). SBP trajectory group was independently associated with functional outcome at 90 days (P<0.0001) after adjusting for potential confounders. Patients with high and high-to-moderate SBP trajectories had significantly greater odds of an unfavorable outcome (adjusted odds ratio, 3.5 [95% CI, 1.8-6.7], P=0.0003 and adjusted odds ratio, 2.2 [95% CI, 1.5-3.2], P<0.0001, respectively). Subjects in the high-to-moderate group had an increased risk of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.82 [95% CI, 1-3.2]; P=0.04). No significant association was found between trajectory group and hemorrhagic transformation. CONCLUSIONS Patients with acute ischemic stroke demonstrate distinct SBP trajectories during the first 72 hours after EVT that have differing associations with functional outcome. These findings may help identify potential candidates for future blood pressure modulation trials.
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Affiliation(s)
- Nils H Petersen
- Department of Neurology (N.H.P., S.K., C.K.N., K.U.P., S.S., A.S., A.K., A.W., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Sreeja Kodali
- Department of Neurology (N.H.P., S.K., C.K.N., K.U.P., S.S., A.S., A.K., A.W., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Can Meng
- Department of Neurosurgery (C.M), Yale University School of Medicine, New Haven, CT
| | - Fangyong Li
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT (C.M., F.L.)
| | - Cindy Khanh Nguyen
- Department of Neurology (N.H.P., S.K., C.K.N., K.U.P., S.S., A.S., A.K., A.W., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Krithika U Peshwe
- Department of Neurology (N.H.P., S.K., C.K.N., K.U.P., S.S., A.S., A.K., A.W., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Sumita Strander
- Department of Neurology (N.H.P., S.K., C.K.N., K.U.P., S.S., A.S., A.K., A.W., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Andrew Silverman
- Department of Neurology (N.H.P., S.K., C.K.N., K.U.P., S.S., A.S., A.K., A.W., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Alexandra Kimmel
- Department of Neurology (N.H.P., S.K., C.K.N., K.U.P., S.S., A.S., A.K., A.W., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Anson Wang
- Department of Neurology (N.H.P., S.K., C.K.N., K.U.P., S.S., A.S., A.K., A.W., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Mohammad Anadani
- Department of Neurology (M.A., E.A.), Medical University of South Carolina, Charleston, SC
| | - Eyad Almallouhi
- Department of Neurology (M.A., E.A.), Medical University of South Carolina, Charleston, SC
| | - Alejandro M Spiotta
- Department of Neurosurgery (A.M.S.), Medical University of South Carolina, Charleston, SC
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea (J.-T.K.)
| | - James A Giles
- Department of Neurology, Washington University School of Medicine in St. Louis, MO (J.A.G., S.G.K.)
| | - Salah G Keyrouz
- Department of Neurology, Washington University School of Medicine in St. Louis, MO (J.A.G., S.G.K.)
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City (M.F., C.Z., S.O.-G.)
| | - Cynthia Zevallos
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City (M.F., C.Z., S.O.-G.)
| | - Ilko L Maier
- Department of Neurology, University Medical Center Göttingen, Germany (I.L.M., J.L.)
| | - Marios-Nikos Psychogios
- Department of Diagnostic and Interventional Neuroradiology, University Clinic Basel, Switzerland (M.-N.P.)
| | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Germany (I.L.M., J.L.)
| | - Nolwenn Riou-Comte
- Department of Neurology (N.R.-C., S.R.), University Hospital of Nancy, France
| | - Sébastien Richard
- Department of Neurology (N.R.-C., S.R.), University Hospital of Nancy, France
- Centre d'Investigation Clinique Plurithématique, INSERM U1116, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France (S.R.)
| | - Benjamin Gory
- Department of Neuroradiology (B.G.), University Hospital of Nancy, France
- IADI, INSERM U1254, University of Lorraine, Nancy, France (B.G.)
| | | | - Patrick A Brown
- Department of Neurology (E.A.M., H.F.), Vanderbilt University Medical Center, Nashville, TN
| | - Kyle M Fargen
- Department of Radiology (P.A.B), Wake Forest School of Medicine, Winston-Salem, NC
| | - Eva A Mistry
- Department of Neurology (E.A.M., H.F.), Vanderbilt University Medical Center, Nashville, TN
| | - Hiba Fakhri
- Department of Neurology (E.A.M., H.F.), Vanderbilt University Medical Center, Nashville, TN
| | - Akshitkumar M Mistry
- Department of Neurosurgery (A.M.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Ka-Ho Wong
- Department of Neurology, University of Utah School of Medicine, Salt Lake City (K.-H.W, A.d.H)
| | - Adam de Havenon
- Department of Neurology, University of Utah School of Medicine, Salt Lake City (K.-H.W, A.d.H)
| | - Fábio A Nascimento
- Department of Neurology, Baylor College of Medicine, Houston, TX (F.A.N, P.K.)
| | - Peter Kan
- Department of Neurology, Baylor College of Medicine, Houston, TX (F.A.N, P.K.)
| | - Charles Matouk
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT (C.M., F.L.)
| | - Santiago Ortega-Gutiérrez
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City (M.F., C.Z., S.O.-G.)
| | - Kevin N Sheth
- Department of Neurology (N.H.P., S.K., C.K.N., K.U.P., S.S., A.S., A.K., A.W., K.N.S.), Yale University School of Medicine, New Haven, CT
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9
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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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10
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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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11
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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: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/05/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke.The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
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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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12
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Anadani M, de Havenon A, Mistry E, Anderson CS. Blood Pressure Management After Endovascular Therapy: An Ongoing Debate. Stroke 2021; 52:e263-e265. [PMID: 34000832 DOI: 10.1161/strokeaha.121.034995] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Mohammad Anadani
- Department of Neurology, Washington University in St. Louis School of Medicine, MO (M.A.)
| | | | - Eva Mistry
- Vanderbilt University Medical Center, TN (E.M.)
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.S.A.)
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13
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Carvalho Dias M, Gabriel D, Saraiva M, Campos D, Requena M, García-Tornel Á, Muchada M, Boned S, Rodriguez-Luna D, Rodriguez-Villatoro N, Pagola J, Juega J, Deck M, Ribo M, Tomasello A, Molina CA, Rubiera M. Spontaneous systolic blood pressure drop early after mechanical thrombectomy predicts dramatic neurological recovery in ischaemic stroke patients. Eur Stroke J 2021; 5:362-369. [PMID: 33598554 DOI: 10.1177/2396987320933384] [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: 12/31/2019] [Accepted: 05/18/2020] [Indexed: 01/01/2023] Open
Abstract
Introduction Spontaneous blood pressure drop within the first 24 h has been reported following arterial recanalisation in ischaemic stroke patients. We aimed to assess if spontaneous blood pressure drop within the first hour after mechanical thrombectomy is a marker of early neurological recovery. Patients and methods Retrospective observational single-centre study including ischaemic stroke patients treated with mechanical thrombectomy. Blood pressure parameters from admission, mechanical thrombectomy start, mechanical thrombectomy end and hourly within 24 h after mechanical thrombectomy were reviewed. Primary outcome was early dramatic neurological recovery (8-point-reduction in NIHSS or NIHSS ≤ 2 at 24 h). Secondary outcome was functional independence at 90 days (mRankin 0-2). Results We included 458 patients in our analysis. Two-hundred (43.7%) patients achieved dramatic neurological recovery following mechanical thrombectomy. One hour after mechanical thrombectomy end, median systolic blood pressure was significantly different between outcome groups (129 vs. 138 mmHg, p = 0.005) and a higher drop in median systolic blood pressure was seen in the dramatic neurological recovery group (15 vs. 9 mmHg). Optimal cut-off for predicting dramatic neurological recovery was a systolic blood pressure drop of 10.5 mmHg (sensitivity 0.54, specificity 0.55, AUC 0.55). On multivariate analysis, spontaneous systolic blood pressure drop was associated with higher odds of achieving dramatic neurological recovery (OR for 10 mmHg blood pressure drop 1.14, 95% CI 1.01-1.29, p = 0.04). No significative association between any blood pressure parameter drop and functional independence at 90 days was found. Discussion We hypothesised that spontaneous systolic blood pressure drop is a marker of successful reperfusion and, therefore, a marker of improvement of cerebral autoregulation due to the reduced final ischaemic core. Conclusion Spontaneous systolic blood pressure drop after mechanical thrombectomy is an early predictor of dramatic neurological recovery.
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Affiliation(s)
- Mariana Carvalho Dias
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Denis Gabriel
- Neurology Department, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marlene Saraiva
- Neurology Department, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Daniel Campos
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Marian Muchada
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Sandra Boned
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | - Jorge Pagola
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Jesus Juega
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Matías Deck
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Marc Ribo
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Carlos A Molina
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Marta Rubiera
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
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14
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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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15
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Das S, John KD, Bokka SK, Remmel K, Akça O. Blood Pressure Management Following Large Vessel Occlusion Strokes: A Narrative Review. Balkan Med J 2020; 37:253-259. [PMID: 32475092 PMCID: PMC7424178 DOI: 10.4274/balkanmedj.galenos.2020.2020.4.196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Stroke is one of the leading causes of morbidity and mortality worldwide. Intravenous tissue plasminogen activator and mechanical thrombectomy comprise the two major treatments for acute ischemic stroke. Tissue plasminogen activator has been used for more than two decades and guidelines for hemodynamic management following tissue plasminogen activator administration are well established. However, mechanical thrombectomy is a relatively newer therapy and there is a paucity of evidence regarding hemodynamic management following large vessel occlusion strokes. The important tenets guiding the pathophysiology of large vessel occlusion strokes include understanding of cerebral autoregulation, collateral circulation, and blood pressure variability. In this narrative review, we discuss the current American Heart Association-American Stroke Association guidelines for the early management of acute ischemic stroke during different phases of the illness, encountered at different sections of a hospital including the emergency room, the neuro-interventional suite, and the intensive care unit. There is emerging evidence with regard to post-recanalization blood pressure management following large vessel occlusion strokes. Future research directions will include rea-ltime blood pressure variability assessments, identifying the extent of impaired autoregulation, and providing guidelines related to range and personalized blood pressure trajectories for patients following large vessel occlusion strokes.
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Affiliation(s)
- Saurav Das
- Department of Neurology, Louisville University School of Medicine, Louisville, Kentucky, USA
| | - Kevin Denny John
- University of Louisville, School of Medicine, Louisville, Kentucky, USA
| | - Satheesh Kumar Bokka
- Department of Neurology, Louisville University School of Medicine, Louisville, Kentucky, USA
| | - Kerri Remmel
- Department of Anesthesiology and Perioperative Medicine, Stroke ICU, Louisville University Hospital, Louisville, Kentucky, USA
- Comprehensive Stroke Clinical Research Program, University of Louisville, Louisville, Kentucky, USA
| | - Ozan Akça
- Department of Anesthesiology and Perioperative Medicine, Stroke ICU, Louisville University Hospital, Louisville, Kentucky, USA
- Comprehensive Stroke Clinical Research Program, University of Louisville, Louisville, Kentucky, USA
- * Address for Correspondence: Comprehensive Stroke Clinical Research Program, University of Louisville, Louisville, Kentucky, USA Phone: +90 502 852 58 51 E-mail:
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Anadani M, Arthur AS, Tsivgoulis G, Simpson KN, Alawieh A, Orabi Y, Goyal N, Alexandrov AV, Maier IL, Psychogios M, Liman J, Brinton D, Swisher CB, Shah S, Inamullah O, Keyrouz S, Kansagra AP, Allen M, Giles JA, Wolfe SQ, Fargen KM, Gory B, De Marini P, Kan P, Nascimento FA, Almallouhi E, Petersen N, Kodali S, Rahman S, Richard S, Spiotta AM. Blood Pressure Goals and Clinical Outcomes after Successful Endovascular Therapy: A Multicenter Study. Ann Neurol 2020; 87:830-839. [DOI: 10.1002/ana.25716] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Mohammad Anadani
- Department of NeurosurgeryMedical University of South Carolina Charleston SC USA
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Adam S. Arthur
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Georgios Tsivgoulis
- Department of NeurosurgeryUniversity of Tennessee Health Science Center Memphis TN USA
| | - Kit N. Simpson
- Department of NeurologyAttikon University Hospital, School of Medicine, National and Kapodistrian University of Athens Athens Greece
| | - Ali Alawieh
- Department of NeurosurgeryMedical University of South Carolina Charleston SC USA
| | - Yser Orabi
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Nitin Goyal
- Department of NeurologyUniversity Medical Center Göttingen Göttingen Germany
| | - Andrei V. Alexandrov
- Department of NeurologyUniversity of Tennessee Health Science Center Memphis TN USA
| | - Ilko L. Maier
- Department of NeurologyUniversity Medical Center Göttingen Göttingen Germany
| | | | - Jan Liman
- Department of NeurologyUniversity Medical Center Göttingen Göttingen Germany
| | - Daniel Brinton
- Department of Healthcare Leadership and ManagementMedical University of South Carolina Charleston SC USA
| | | | - Shreyash Shah
- Department of NeurologyDuke University Hospital Durham NC USA
| | - Ovais Inamullah
- Department of NeurologyDuke University Hospital Durham NC USA
| | - Salah Keyrouz
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - Akash P. Kansagra
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - Michelle Allen
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - James A. Giles
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - Stacey Q. Wolfe
- Department of NeurosurgeryWake Forest University Winston‐Salem NC USA
| | - Kyle M. Fargen
- Department of NeurosurgeryWake Forest University Winston‐Salem NC USA
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic NeuroradiologyUniversity Hospital of Nancy Nancy France
| | - Pierre De Marini
- Department of Diagnostic and Therapeutic NeuroradiologyUniversity Hospital of Nancy Nancy France
| | - Peter Kan
- Department of NeurosurgeryBaylor College of Medicine Houston TX USA
| | | | - Eyad Almallouhi
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Nils Petersen
- Department of NeurologyYale New Haven Hospital New Haven CT USA
| | - Sreeja Kodali
- Department of NeurologyYale New Haven Hospital New Haven CT USA
| | - Shareena Rahman
- Department of NeurologyDuke University Hospital Durham NC USA
| | - Sébastien Richard
- Department of NeurologyStroke Unit, University Hospital of Nancy Nancy France
| | - Alejandro M. Spiotta
- Department of NeurosurgeryMedical University of South Carolina Charleston SC USA
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17
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Blood Pressure Management Following Acute Ischemic Stroke: A Review of Primary Literature. Crit Care Nurs Q 2020; 43:109-121. [PMID: 32084057 DOI: 10.1097/cnq.0000000000000297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Elevated blood pressure is common in patients with acute ischemic stroke. While this may occur secondary to the body's own response to preserve cerebral blood flow, elevated blood pressure may also increase the risk of hemorrhagic transformation. Current guidelines recommend various blood pressure goals based upon multiple factors, including thresholds specific to certain treatment interventions. Despite these guidelines, there is limited evidence to support specific blood pressure targets, and variability in clinical practice is common. The purpose of this review was to discuss blood pressure management in adult patients with acute ischemic stroke, focusing on appropriate targets in the setting of alteplase administration, mechanical thrombectomy, and hemorrhagic transformation.
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18
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Malhotra K, Goyal N, Katsanos AH, Filippatou A, Mistry EA, Khatri P, Anadani M, Spiotta AM, Sandset EC, Sarraj A, Magoufis G, Krogias C, Tönges L, Safouris A, Elijovich L, Goyal M, Arthur A, Alexandrov AV, Tsivgoulis G. Association of Blood Pressure With Outcomes in Acute Stroke Thrombectomy. Hypertension 2020; 75:730-739. [PMID: 31928111 DOI: 10.1161/hypertensionaha.119.14230] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Limited data exist evaluating the effect of blood pressure (BP) on clinical outcomes among patients with acute ischemic stroke with large vessel occlusion treated with mechanical thrombectomy (MT). We sought to evaluate the association of BP levels on clinical outcomes among patients with acute ischemic stroke with large vessel occlusion treated with MT. Studies were identified that reported the association of systolic BP (SBP) or diastolic BP levels before, during, or after MT on the outcomes of patients with acute ischemic stroke treated with MT. Unadjusted and adjusted analyses of studies reporting odds ratios (ORadj) per 10 mm Hg BP increment were performed. Our analysis included 25 studies comprising 6474 patients. Higher pre-MT mean SBP (P=0.008) and post-MT maximum SBP (P=0.009) levels were observed in patients who died within 3 months. Patients with 3-month functional independence were noted to have lower pre-MT (P<0.001) and post-MT maximum SBP levels (P<0.001). In adjusted analyses, increasing post-MT maximum SBP and diastolic BP levels were associated with 3-month mortality (ORadj, 1.19 [95% CI,1.00-1.43]; I2=78%, P value for Cochran Q test: 0.001) and symptomatic intracranial hemorrhage (ORadj, 1.65 [95% CI, 1.11-2.44]; I2=0%, P value for Cochran Q test: 0.80), respectively. Increasing pre- and post-MT mean SBP levels were associated with lower odds of 3-month functional independence (ORadj, 0.86 [95% CI, 0.77-0.96]; I2=18%, P value for Cochran Q test: 0.30) and (ORadj, 0.80 [95% CI, 0.72-0.89]; I2=0%, P value for Cochran Q test: 0.51), respectively. In conclusion, elevated BP levels before and after MT are associated with adverse outcomes among patients with acute ischemic stroke with large vessel occlusion.
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Affiliation(s)
- Konark Malhotra
- From the Department of Neurology, Allegheny Health Network, Pittsburgh, PA (K.M.)
| | - Nitin Goyal
- Department of Neurology, University of Tennessee, Memphis (N.G., A.V.A., G.T.)
| | - Aristeidis H Katsanos
- Department of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K.)
| | - Angeliki Filippatou
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Greece (A.F., G.T.)
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University, Nashville, TN (E.A.M.)
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, OH (P.K.)
| | - Mohammad Anadani
- Department of Neurology, Washington University School of Medicine, St Louis, MO (M.A.).,Department of Neurosurgery, Medical University of South Carolina, Charleston (M.A., A.M.S.)
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston (M.A., A.M.S.)
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Norway (E.C.S.).,The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S.)
| | - Amrou Sarraj
- Department of Neurology, UT Houston, TX (A. Sarraj)
| | - Georgios Magoufis
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M., A. Safouris)
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany (C.K., L.T.)
| | - Lars Tönges
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany (C.K., L.T.)
| | | | - Lucas Elijovich
- Department of Neurosurgery, University of Tennessee/Semmes-Murphey Clinic, Memphis (L.E., A.A.)
| | - Mayank Goyal
- Departments of Radiology and Clinical Neurosciences, University of Calgary, AB, Canada (M.G.)
| | - Adam Arthur
- Department of Neurosurgery, University of Tennessee/Semmes-Murphey Clinic, Memphis (L.E., A.A.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee, Memphis (N.G., A.V.A., G.T.)
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee, Memphis (N.G., A.V.A., G.T.).,Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Greece (A.F., G.T.)
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19
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Matusevicius M, Cooray C, Bottai M, Mazya M, Tsivgoulis G, Nunes AP, Moreira T, Ollikainen J, Tassi R, Strbian D, Toni D, Holmin S, Ahmed N. Blood Pressure After Endovascular Thrombectomy: Modeling for Outcomes Based on Recanalization Status. Stroke 2019; 51:519-525. [PMID: 31822252 DOI: 10.1161/strokeaha.119.026914] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background and Purpose- The optimal level for blood pressure after endovascular thrombectomy in acute ischemic stroke is not well established. We sought to evaluate the association of post-endovascular thrombectomy systolic blood pressure (SBP) levels with clinical outcomes. Methods- We included endovascular thrombectomy-treated patients registered from 2014 to 2017 in the Safe Implementation of Treatments in Stroke International Thrombectomy Registry. The mean 24-hour SBP after endovascular thrombectomy treatment was analyzed both as a continuous variable and in intervals. The primary outcome was 3-month functional independence (modified Rankin Scale score of 0-2). The secondary outcomes were symptomatic intracerebral hemorrhage (SICH) and 3-month mortality. The SBP interval with the highest proportion of functional independence was chosen as reference. All analyses were performed for successful or unsuccessful recanalization (modified Treatment in Cerebral Ischemia score ≥2b or <2b, respectively). The results were adjusted for known confounders in logistic regression models. Results- In the multivariable analyses, a higher SBP value as a continuous variable was associated unfavorably with all outcomes in patients with successful recanalization (n=2920) and with more SICH in patients with unsuccessful recanalization (n=711). SBP interval ≥160 mm Hg was associated with less functional independence (adjusted odds ratio, 0.28 [95% CIs, 0.15-0.53]) and more SICH (adjusted odds ratio, 6.82 [95% CIs, 1.53-38.09]) compared with reference 100 to 119 mm Hg in patients with successful recanalization. SBP ≥160 mm Hg was associated with more SICH (adjusted odds ratio, 6.62 [95% CIs, 1.07-51.05]) compared with reference 120 to 139 mm Hg in patients with unsuccessful recanalization. Conclusions- Higher SBP values were associated with less functional independence at 3 months in patients with successful recanalization and with more SICH regardless of recanalization status.
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Affiliation(s)
- Marius Matusevicius
- From the Department of Clinical Neuroscience (M. Matusevicius, C.C., M. Mazya, T.M., S.H., N.A.), Karolinska Institutet, Stockholm, Sweden
| | - Charith Cooray
- From the Department of Clinical Neuroscience (M. Matusevicius, C.C., M. Mazya, T.M., S.H., N.A.), Karolinska Institutet, Stockholm, Sweden.,Department of Neurovascular Disease (C.C., M. Mazya, T.M., N.A.), Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine (M.B.), Karolinska Institutet, Stockholm, Sweden
| | - Michael Mazya
- From the Department of Clinical Neuroscience (M. Matusevicius, C.C., M. Mazya, T.M., S.H., N.A.), Karolinska Institutet, Stockholm, Sweden.,Department of Neurovascular Disease (C.C., M. Mazya, T.M., N.A.), Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (G.T.)
| | - Ana Paiva Nunes
- Stroke Unit, Centro Hospitalar Lisboa Central, Lisbon, Portugal (A.P.N.)
| | - Tiago Moreira
- From the Department of Clinical Neuroscience (M. Matusevicius, C.C., M. Mazya, T.M., S.H., N.A.), Karolinska Institutet, Stockholm, Sweden.,Department of Neurovascular Disease (C.C., M. Mazya, T.M., N.A.), Karolinska University Hospital, Stockholm, Sweden
| | - Jyrki Ollikainen
- Department of Neurosciences and Rehabilitation, Tampere University, Finland (J.O.)
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Finland (D.S.)
| | - Danilo Toni
- Department of Human Neurosciences, University La Sapienza, Rome, Italy (D.T.)
| | - Staffan Holmin
- From the Department of Clinical Neuroscience (M. Matusevicius, C.C., M. Mazya, T.M., S.H., N.A.), Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology (S.H.), Karolinska University Hospital, Stockholm, Sweden
| | - Niaz Ahmed
- From the Department of Clinical Neuroscience (M. Matusevicius, C.C., M. Mazya, T.M., S.H., N.A.), Karolinska Institutet, Stockholm, Sweden.,Department of Neurovascular Disease (C.C., M. Mazya, T.M., N.A.), Karolinska University Hospital, Stockholm, Sweden
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20
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Kim SH, Kim JI, Lee JY, Park CI, Hong JY, Lee SS. Is spontaneous normalization of systolic blood pressure within 24 hours after ischemic stroke onset related with favorable outcomes? PLoS One 2019; 14:e0224293. [PMID: 31639163 PMCID: PMC6804986 DOI: 10.1371/journal.pone.0224293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 10/09/2019] [Indexed: 11/18/2022] Open
Abstract
Background In acute ischemic stroke, blood pressure (BP) tends to rise initially and fall to a baseline level within 24–48 hours. Previous studies reported several different effects of BPs during acute ischemic stroke on clinical outcomes, which was partly due to the different time intervals from stroke onset to BP measurement. Methods All patients with acute ischemic stroke (onset ≤3 hours) who lived independently before the stroke, were consecutively enrolled for a 62-month period. BPs at 0, 12, and 24 hours after admission were collected. A favorable outcome was defined as a modified Rankin Scale (mRS) score 0–2 at discharge. For different standards of BP management, patients were grouped and analyzed according to intravenous (IV) tissue plasminogen activator (tPA) treatment and favorable outcome. Results Among the 446 enrolled patients, 227 patients underwent IV tPA treatment and 216 had mRS score 0–2 at discharge. Patients with favorable outcomes had lower initial NIH Stroke Scale (NIHSS) scores, less frequent progressive neurological deficits, and lower systolic BP (SBP) 12 and 24 hours after admission than patients with unfavorable outcomes, regardless of whether they underwent tPA treatment or not (p <0.05). The BP decreased over a period of 24 hours after admission. In logistic regression analysis, the independent variables associated with favorable outcome were the initial NIHSS score, a progressive neurological deficit, a previous stroke, and the SBP 24 hours after admission in the patients who underwent tPA treatment and the initial NIHSS score and a progressive neurological deficit in the patients who did not undergo tPA treatment (p <0.05). Conclusions The SBPs at 12 and 24 hours after admission were lower in acute stroke patients with favorable outcomes than in the other patients, regardless of whether the patients underwent tPA therapy and the SBP at 24 hours was an independent predictor of favorable outcomes among the patients who underwent tPA treatment.
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Affiliation(s)
- Seo Hyun Kim
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
- * E-mail:
| | - Ji In Kim
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Ji-Yong Lee
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Chan Ik Park
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Jin Yong Hong
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Sung-Soo Lee
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
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21
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Bulwa Z, Gomez CR, Morales-Vidal S, Biller J. Management of Blood Pressure After Acute Ischemic Stroke. Curr Neurol Neurosci Rep 2019; 19:29. [PMID: 31037389 DOI: 10.1007/s11910-019-0941-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The present manuscript examines the significance of blood pressure elevation in patients with acute ischemic stroke, the physiologic principles worthy of consideration during its treatment, and the recent empirical evidence that should guide management protocols. It also provides a sound and practical approach to treatment along the time continuum, with particular relevance to reperfusion strategies. RECENT FINDINGS The existing evidence shows that both insufficient and excessive blood pressures are detrimental to the outcome of patients with acute ischemic stroke. This "U-shaped" relation, however, relates to measurements at the time of presentation, and clinical studies lack detail and specificity relative to differential measurements along the time continuum, particularly prior to and following reperfusion. Extrapolating from recent series, it is possible to construct treatment protocols balanced for effectiveness and safety. The management of blood pressure after acute ischemic stroke is an important, complex, and challenging aspect of care, requiring a thorough understanding of cerebrovascular physiology. Along the time continuum, the therapeutic priorities start with the preservation of penumbral tissue prior to reperfusion and then follow with the limitation of the damaging effects of excessive blood pressure readings after reperfusion, optimizing the chances of improved outcomes.
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Affiliation(s)
- Zachary Bulwa
- Department of Neurology, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri Columbia, Columbia, MO, USA.
| | - Sarkis Morales-Vidal
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
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22
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Anadani M, Orabi Y, Alawieh A, Chatterjee A, Lena J, Al Kasab S, Spiotta AM. Blood pressure and outcome post mechanical thrombectomy. J Clin Neurosci 2019; 62:94-99. [DOI: 10.1016/j.jocn.2018.12.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/08/2018] [Accepted: 12/11/2018] [Indexed: 12/12/2022]
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23
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Cernik D, Sanak D, Divisova P, Kocher M, Cihlar F, Zapletalova J, Veverka T, Prcuchova A, Ospalik D, Cerna M, Janousova P, Kral M, Dornak T, Prasil V, Franc D, Kanovsky P. Impact of blood pressure levels within first 24 hours after mechanical thrombectomy on clinical outcome in acute ischemic stroke patients. J Neurointerv Surg 2019; 11:735-739. [PMID: 30728203 DOI: 10.1136/neurintsurg-2018-014548] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/12/2018] [Accepted: 12/17/2018] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Despite early management and technical success of mechanical thrombectomy (MT) for acute ischemic stroke (AIS), not all patients reach a good clinical outcome. Different factors may have an impact and we aimed to evaluate blood pressure (BP) levels in the first 24 hours after MT. METHODS Consecutive AIS patients treated with MT were enrolled in the retrospective bi-center study. Neurological deficit was assessed with National Institutes of Health Stroke Scale (NIHSS) and functional outcome after 3 months with modified Rankin scale (mRS) with a score 0-2 for good outcome. The presence of symptomatic intracerebral hemorrhage (SICH) was assessed according to the SITS-MOST criteria. RESULTS Of 703 treated patients, completed BP levels were collected in 690 patients (350 males, mean age 71±13 years) with median of admission NIHSS 17 points. Patients with mRS 0-2 had a lower median of systolic BP (SBP) compared with those with poor outcome (131 vs 140 mm Hg, P<0.0001). The rate of SICH did not differ between the patients with a median of SBP <140 mm Hg and ≥140 mm Hg. (5.1% vs 5.1%, P=0.980). Multivariate regression analysis with adjustment for potential confounders showed a median of distolic BP (P=0.024, OR: 0.977, 95% CI: 0.957 to 0.997) as a predictor of good functional outcome after MT, and a median of maximal SBP (P=0.038; OR: 0.990, 95% CI: 0.981 to 0.999) in the patients with achieved recanalization. CONCLUSION Lowering of BP within the first 24 hours after MT may have a positive impact on clinical outcome in treated patients.
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Affiliation(s)
- David Cernik
- Department of Neurology, Krajska zdravotni as Masarykova nemocnice v Usti nad Labem oz, Usti nad Labem, Czech Republic
| | - Daniel Sanak
- Department of Neurology, Univ Hosp Olomouc, Olomouc, Czech Republic
| | - Petra Divisova
- Department of Neurology, Univ Hosp Olomouc, Olomouc, Czech Republic
| | - Martin Kocher
- Department of Radiology, Univ Hosp Olomouc, Olomouc, Czech Republic
| | - Filip Cihlar
- Department of Radiology, Krajska zdravotni as Masarykova nemocnice v Usti nad Labem oz, Usti nad Labem, Czech Republic
| | - Jana Zapletalova
- Department of Biometry and Statistics, Palacký University Medical School, Olomouc, Czech Republic
| | - Tomas Veverka
- Department of Neurology, Univ Hosp Olomouc, Olomouc, Czech Republic
| | - Andrea Prcuchova
- Department of Neurology, Krajska zdravotni as Masarykova nemocnice v Usti nad Labem oz, Usti nad Labem, Czech Republic
| | - Dusan Ospalik
- Department of Neurology, Krajska zdravotni as Masarykova nemocnice v Usti nad Labem oz, Usti nad Labem, Czech Republic
| | - Marie Cerna
- Department of Radiology, Univ Hosp Olomouc, Olomouc, Czech Republic
| | - Petra Janousova
- Department of Neurology, Univ Hosp Olomouc, Olomouc, Czech Republic
| | - Michal Kral
- Department of Neurology, Univ Hosp Olomouc, Olomouc, Czech Republic
| | - Tomas Dornak
- Department of Neurology, Univ Hosp Olomouc, Olomouc, Czech Republic
| | - Vojtech Prasil
- Department of Radiology, Univ Hosp Olomouc, Olomouc, Czech Republic
| | - David Franc
- Department of Neurology, Univ Hosp Olomouc, Olomouc, Czech Republic
| | - Petr Kanovsky
- Department of Neurology, Univ Hosp Olomouc, Olomouc, Czech Republic
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Li J, Wang C, Zou S, Liu Y, Qu L. Hybrid Surgery for Nontaper or Nonstump Lesions in Symptomatic Subacute or Chronic Internal Carotid Occlusion: A Better Solution. World Neurosurg 2018; 122:e1416-e1425. [PMID: 30458323 DOI: 10.1016/j.wneu.2018.11.075] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/06/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Internal carotid artery occlusion (ICAO) causes transient ischemic attack and cerebral infarction. ICAO management remains clinically challenging. We discuss a hybrid treatment combining carotid endarterectomy and endovascular intervention (E-I) for patients with nontaper or nonstump lesions of symptomatic ICAO. METHODS We treated 32 patients with consecutive nontaper or nonstump ICAO with neurological symptoms with hybrid treatment or E-I. We analyzed the epidemiology, symptoms, angiographic morphology, technical success rate, and perioperative complications. RESULTS Of the 32 patients, 17 were treated with hybrid surgery and 15, E-I. The demographic data and lesion characteristics were similar between the 2 groups. The overall recanalization success rate was 71.9%. The rate for hybrid surgery was better than that for E-I (88.2% vs. 53.3%). The postoperative cerebral hyperperfusion rate showed no difference between the 2 groups (11.8% vs. 6.7%). Ipsilateral cerebral perfusion improved after treatment. The mean transition time and time to peak were greater than normal (normal values, <6 seconds and <8 seconds, respectively). Both increased significantly after treatment (mean transition time, 11.30 seconds vs. 7.25 seconds; time to peak, 19.30 seconds vs. 15.50 seconds). The incidence of perioperative complications from hybrid surgery was less than that with E-I (5.9% vs. 40.0%). Recurrent cerebrovascular events (5.9% vs. 13.3%) and the 3-month modified Rankin scale score (2.76 ± 0.66 vs. 2.93 ± 0.70) did not differ between the 2 groups. CONCLUSIONS Recanalization of nontaper or nonstump ICAO with hybrid treatment was more successful than that with E-I, with fewer perioperative complications. The carotid endarterectomy procedure enables easier wire crossing across the occlusion and reduces potential technology-related complications by requiring a shorter lesion and fewer dissections and minimizing the effect of calcification.
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Affiliation(s)
- Jun Li
- Department of Vascular and Endovascular Surgery, Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai, China
| | - Chao Wang
- Department of Vascular and Endovascular Surgery, Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai, China
| | - Sili Zou
- Department of Vascular and Endovascular Surgery, Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai, China
| | - Yandong Liu
- Department of Vascular and Endovascular Surgery, Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai, China
| | - Lefeng Qu
- Department of Vascular and Endovascular Surgery, Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai, China.
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25
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Pikija S, Trkulja V, Ramesmayer C, Mutzenbach JS, Killer-Oberpfalzer M, Hecker C, Bubel N, Füssel MU, Sellner J. Higher Blood Pressure during Endovascular Thrombectomy in Anterior Circulation Stroke Is Associated with Better Outcomes. J Stroke 2018; 20:373-384. [PMID: 30309232 PMCID: PMC6186925 DOI: 10.5853/jos.2018.01305] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/17/2018] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose Reports investigating the relationship between in-procedure blood pressure (BP) and outcomes in patients undergoing endovascular thrombectomy (EVT) due to anterior circulation stroke are sparse and contradictory.
Methods Consecutive EVT-treated adults (modern stent retrievers, BP managed in line with the recommendations, general anesthesia, invasive BP measurements) were evaluated for associations of the rate of in-procedure systolic BP (SBP) and mean arterial pressure (MAP) excursions to >120%/<80% of the reference values (serial measurements at anesthesia induction) and of the reference BP/weighted in-procedure mean BP with post-procedure imaging outcomes (ischemic lesion volume [ILV], hemorrhages) and 3-month functional outcome (modified Rankin Scale [mRS], score 0 to 2 vs. 3 to 6).
Results Overall 164 patients (70.7% pharmacological reperfusion, 80.5% with good collaterals, 73.8% with successful reperfusion) were evaluated for ILV (range, 0 to 581 cm3) and hemorrhages (incidence 17.7%). Higher rate of in-procedure SBP/MAP excursions to >120% was independently associated with lower ILV, while higher in-procedure mean SBP/MAP was associated with lower odds of hemorrhages. mRS 0-2 was achieved in 75/155 (48.4%) evaluated patients (nine had missing mRS data). Higher rate of SBP/MAP excursions to >120% and higher reference SBP/MAP were independently associated with higher odds of mRS 0-2, while higher ILV was associated with lower odds of mRS 0-2. Rate of SBP/MAP excursions to <80% was not associated with any outcome.
Conclusions In the EVT-treated patients with BP managed within the recommended limits, a better functional outcome might be achieved by targeting in-procedure BP that exceeds the preprocedure values by more than 20%.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Vladimir Trkulja
- Department for Pharmacology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Christian Ramesmayer
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Johannes S Mutzenbach
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Institute for Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Constantin Hecker
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Nele Bubel
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Michael Ulrich Füssel
- Institute of Neuroanesthesiology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, Rechts der Isar Hospital, Technical University of Munich, Munchen, Germany
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Acute Blood Pressure Management in Acute Ischemic Stroke and Spontaneous Cerebral Hemorrhage. Curr Treat Options Neurol 2018; 20:39. [DOI: 10.1007/s11940-018-0523-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Xu B, Li C, Guo Y, Xu K, Yang Y, Yu J. Current understanding of chronic total occlusion of the internal carotid artery. Biomed Rep 2017; 8:117-125. [PMID: 29435269 PMCID: PMC5776422 DOI: 10.3892/br.2017.1033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/12/2017] [Indexed: 01/08/2023] Open
Abstract
At present, there is limited understanding of chronic total occlusion (CTO) of the internal carotid artery (ICA). Therefore, the present report collected related cases from PubMed and reviewed the literature. Cerebral vessels may form collateral circulation immediately or gradually following CTO of the ICA. The natural history of CTO of the ICA includes a variety of outcomes, all of which are biased toward a non-benign progressive process and are characterized by insufficient cerebral perfusion, embolus detachment and cognitive dysfunction. The majority of cases of CTO of the ICA require treatment. In early studies, the results of external-ICA bypass were unsatisfactory, while recanalization is now considered the only viable option. The current treatment indications mainly depend on the degree of injury to the cerebrovascular reserve and the extent to which the oxygen extraction fraction is increased. The length, height and duration of ICA occlusion are also relevant, though more frequently, the condition depends on multiple factors. Endovascular interventional recanalization, carotid endarterectomy (CEA) and hybrid surgery may be conducted in a select group of patients. As novel materials are developed, the success rate of simple recanalization may gradually increase; however, hybrid surgery may be more representative of the current trend, as advanced CEA can remove carotid atherosclerosis plaques, thus reducing the technological demands of the subsequent interventional recanalization. There are many complications that may result from recanalization following CTO of the ICA, including hyperperfusion and technical errors; therefore, the operation must be conducted carefully. If the recanalization is successful, it typically results in a stable improvement of patient condition in the long term. However, despite these conclusions, more studies are required in the future to further improve current understanding of CTO of the ICA.
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Affiliation(s)
- Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Chao Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yi Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Regenhardt RW, Das AS, Stapleton CJ, Chandra RV, Rabinov JD, Patel AB, Hirsch JA, Leslie-Mazwi TM. Blood Pressure and Penumbral Sustenance in Stroke from Large Vessel Occlusion. Front Neurol 2017; 8:317. [PMID: 28717354 PMCID: PMC5494536 DOI: 10.3389/fneur.2017.00317] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/16/2017] [Indexed: 12/11/2022] Open
Abstract
The global burden of stroke remains high, and of the various subtypes of stroke, large vessel occlusions (LVOs) account for the largest proportion of stroke-related death and disability. Several randomized controlled trials in 2015 changed the landscape of stroke care worldwide, with endovascular thrombectomy (ET) now the standard of care for all eligible patients. With the proven success of this therapy, there is a renewed focus on penumbral sustenance. In this review, we describe the ischemic penumbra, collateral circulation, autoregulation, and imaging assessment of the penumbra. Blood pressure goals in acute stroke remain controversial, and we review the current data and suggest an approach for induced hypertension in the acute treatment of patients with LVOs. Finally, in addition to reperfusion and enhanced perfusion, efforts focused on developing therapeutic targets that afford neuroprotection and augment neural repair will gain increasing importance. ET has revolutionized stroke care, and future emphasis will be placed on promoting penumbral sustenance, which will increase patient eligibility for this highly effective therapy and reduce overall stroke-related death and disability.
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Affiliation(s)
- Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alvin S. Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Christopher J. Stapleton
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ronil V. Chandra
- Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, VIC, Australia
| | - James D. Rabinov
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B. Patel
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joshua A. Hirsch
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Thabele M. Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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