Blood pressure levels post mechanical thrombectomy and outcomes in non-recanalized large vessel occlusion patients

Hemorrhagic Transformation of Ischemic Strokes

Ischemic stroke, resulting from insufficient blood supply to the brain, is among the leading causes of death and disability worldwide. A potentially severe complication of the disease itself or its treatment aiming to restore optimal blood flow is hemorrhagic transformation (HT) increasing morbidity and mortality. Detailed summaries can be found in the literature on the pathophysiological background of hemorrhagic transformation, the potential clinical risk factors increasing its chance, and the different biomarkers expected to help in its prediction and clinical outcome. Clinicopathological studies also contribute to the improvement in our knowledge of hemorrhagic transformation. We summarized the clinical risk factors of the hemorrhagic transformation of ischemic strokes in terms of risk reduction and collected the most promising biomarkers in the field. Also, auxiliary treatment options in reperfusion therapies have been reviewed and collected. We highlighted that the optimal timing of revascularization treatment for carefully selected patients and the individualized management of underlying diseases and comorbidities are pivotal. Another important conclusion is that a more intense clinical follow-up including serial cranial CTs for selected patients can be recommended, as clinicopathological investigations have shown HT to be much more common than clinically suspected.

Good outcome associated with blood-brain barrier disruption and lower blood pressure after endovascular therapy

OBJECTIVES

To evaluate the association between post-endovascular thrombectomy (EVT) blood-brain barrier (BBB) disruption on MRI or CT and average systolic blood pressure (SBP) with favorable 90-day functional outcome. Observational studies have found elevated SBP associated with worse outcomes post-EVT, while recent randomized trials found no difference in targeted BP reduction. There may be a subgroup of patients who benefit from targeted BP reduction post-EVT.

METHODS

This is a single-center study of 1) anterior large vessel occlusion stroke patients treated with EVT from 2015 to 2021, 2) achieved mTICI grade 2b or 3. Hyperintense acute reperfusion marker (HARM), hemorrhagic transformation (HT), and midline shift at 3 h post-EVT and 24 h imaging were assessed independently by multiple raters. Binary logistic regression models were used to determine the association of post-EVT SBP with outcomes. BBB disruption was defined as HT or HARM on 3h post-EVT imaging.

RESULTS

Of 103 patients, those with SBP 100-129 versus SBP 130-160 found no significant difference in favorable 90-day outcome (64% vs. 46%, OR 2.11, 95% CI 0.78-5.76, p=0.143). However, among 71 patients with BBB disruption, a significant difference in favorable outcome of 64% in SBP 100-129 vs. 39% in SBP 130-160 group (OR 5.93, 95% CI 1.50-23.45, p=0.011) was found. There was no difference in symptomatic ICH, 90-day mortality, midline shift (≥5 mm), and hemicraniectomy, between BP or BBB groups.

CONCLUSIONS

BBB disruption on 3h post-EVT imaging and lower SBP was associated with favorable outcome. This imaging finding may guide targeted BP therapy and suggests need for a randomized control trial.

Impact of leukoaraiosis or blood pressure on clinical outcome, mortality and symptomatic intracerebral hemorrhage after mechanical thrombectomy in acute ischemic stroke

We aimed to study the impact of leukoaraiosis (LA) and blood pressure (BP) on clinical outcome, mortality and symptomatic intracerebral hemorrhage (sICH) in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). We analyzed data retrospectively from 521 patients with anterior large vessel occlusion treated with MT. LA was dichotomized in 0-2 (absent-to-moderate) versus 3-4 (moderate-to-severe) according to the van Swieten scale. Various systolic (SBP) and diastolic (DBP) BP parameters during the first 24 h were collected. Multivariable logistic regressions were performed to identify predictors of a poor 90-day outcome, mortality and sICH. LA was significantly associated with poor outcome (OR 3.2; p < 0.001) and mortality (OR 3.19; p = 0.008), but not sICH (p = 0.19). Higher maximum SBP was significantly associated with poor outcome (OR per 10 mmHg increase = 1.21; p = 0.009) and lower mean DBP was a predictor of mortality (OR per 10 mmHg increase = 0.53; p < 0.001). In the univariate analysis high SBP variability was associated with poor outcome, mortality and sICH, but not in the multivariate model. There was no association between BP and sICH. Severity of LA, SBP variability, high maximum SBP and low DBP are associated with either poor outcome or mortality in AIS patients undergoing MT. However, neither LA nor BP were associated with sICH in our cohort. Thus, mechanisms of the negative impact on outcome remain unclear. Further studies on impact of BP course and its mechanisms and interventions are needed to improve outcome in patients undergoing MT.

Effect of blood pressure on the prognosis of acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization

PURPOSE

To explore the effect of blood pressure on the prognosis of acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization.

METHODS

Acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization were retrospectively collected. All patients were divided into the functional independent group and non-functional independent group, death group and non-death group based on the 90-day mRS score. Logistic regression was applied to analyze the relationship between the highest systolic blood pressure, the average systolic blood pressure, the lowest systolic blood pressure, the highest diastolic blood pressure, the average diastolic blood pressure, the lowest diastolic blood pressure in the first 24 h after admission and the functional prognosis as well as the complications after 90 days. The independent impact factors selected from regression analysis were used to investigate the blood pressure with prognostic value by receiver operating characteristic curve (ROC).

RESULTS

A total of 70 patients were recruited in this study. Among them, 39 cases (55.71%) were male and 31 cases (44.29%) were female, with a mean age of 61.83 ± 15.24 years old. 15 cases (21.43%) had a favorable 90-day outcome, and the other 55 cases (78.57%) had a higher mRS Score. After a 90-day follow-up, univariate analysis showed that hypertension and hyperlipidemia, highest systolic blood pressure, mean systolic blood pressure and NIHSS score were statistically significant in two groups with or without functional independence, while the NIHSS score at admission, systolic blood pressure at admission, average systolic blood pressure, highest systolic blood pressure and diastolic blood pressure were statistically significant in patients with death outcomes (P < 0.05). Multivariate regression analysis suggested that the highest systolic blood pressure was statistically significant (P < 0.05), the further ROC curve results showed the cut-off value of the highest systolic blood pressure was 180.5 mmHg, with a sensitivity of 82.35% and a specificity of 81.13%. The highest Youden's index was 0.6348.

CONCLUSION

For acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization, the appropriate reduction of blood pressure within 24 h after admission may have a positive effect on the clinical prognosis. The 90-day mortality of acute ischemic stroke patients without revascularization was independently related to the highest systolic blood pressure. The risk of death was increased when the highest systolic blood pressure was greater than 180.5 mmHg.

Increased blood pressure variability during general anaesthesia is associated with worse outcomes after mechanical thrombectomy: a prospective observational cohort study

OBJECTIVES

Optimal periprocedural blood pressure (BP) management during mechanical thrombectomy (MT) for acute ischaemic stroke is still controversial. The aim of this study was to investigate the association between intraprocedural BP variability (BPV) and outcomes in patients with large vessel occlusion (LVO) following MT with general anaesthesia.

DESIGN

A prospective observational cohort study.

SETTING

This study was conducted in a single tertiary hospital of Hangzhou in Zhejiang province.

PARTICIPANTS

A total of 141 patients with LVO treated with MT were finally included between January 2018 and September 2020.

MAIN OUTCOME MEASURES

Intraprocedural BP was recorded every 5 min throughout the procedure. BPV was measured as SD, coefficient of variation (CV), max-min (RANGE) and successive variation. Haemorrhagic transformation was assessed on 24-hour CT images according to European Cooperative Acute Stroke Study III trial. Poor functional outcome was defined as 90-day modified Rankin Scale score 3-6. Binary logistic regression analysis was used to investigate the association of BPV parameters with the incidence of parenchymal haemorrhage (PH) and poor functional outcome.

RESULTS

After controlling for age, female, history of smoking, hypertension and atrial fibrillation, baseline National Institutes of Health Stroke Scale, baseline systolic BP (SBP), baseline Alberta Stroke Program Early CT Score, bridging thrombolysis and times of retrieval attempts, the results demonstrated that intraprocedural SBP_RANGE (OR 1.029; 95% CI 1.003 to 1.055; p=0.027), SBP_SD (OR 1.135; 95% CI 1.023 to 1.259; p=0.017) and SBP_CV (OR 1.189; 95% CI 1.053 to 1.342; p=0.005) were independently associated with poor functional outcome. However, the independent association between intraprocedural BPV and PH at 24 hours has not been established in this study.

CONCLUSIONS

Increased intraprocedural BPV was more likely to have poor functional outcome in patients with LVO following MT with general anaesthesia. This finding indicates that special precautions should be taken to minimise BP fluctuation during procedure.

[Update on Intensive Care Unit Management of Stroke]

In this review, we provide an update on the intensive care unit (ICU) management of ischemic stroke. Over the last decade, new evidence has led to rapid changes in the early management of patients admitted with acute ischemic stroke. Nevertheless, stroke remains a leading cause of disability. Consequently, a significant number of patients with acute ischemic stroke require ICU level care. The most frequent reasons for ICU admissions are large infarction with potential swelling, reduced level of consciousness, secondary hemorrhagic transformation, acute symptomatic seizures or respiratory failure and stroke-related disorders of the brain-heart interaction. Moreover, there is an increasing number of patients receiving intravenous thrombolysis or mechanical thrombectomy with a subsequent need of ICU monitoring. Several studies have shown that the implementation of specialized neuro-intensive care teams help to improve functional outcome after acute ischemic stroke. The main goal in the ICU management of stroke patients is to prevent secondary brain injury. To this end, a comprehensive approach to optimize systemic physiological homeostasis, control intracranial pressure, cerebral perfusion, hemodynamic and respiratory parameters is needed. Here, we summarize recent advances in invasive and non-invasive neuro-monitoring, decision making in decompressive neurosurgery for large supratentorial or cerebellar infarction, specific cardiorespiratory management, nutrition, temperature management and mobilization strategies in ischemic stroke.

Association between systolic blood pressure course and outcomes after stroke thrombectomy

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.

Remote Ischemic Conditioning in Ischemic Stroke and Myocardial Infarction: Similarities and Differences

Acute myocardial infarction and ischemic stroke are leading causes of morbidity and mortality worldwide. Although reperfusion therapies have greatly improved the outcomes of patients with these conditions, many patients die or are severely disabled despite complete reperfusion. It is therefore important to identify interventions that can prevent progression to ischemic necrosis and limit ischemia-reperfusion injury. A possible strategy is ischemic conditioning, which consists of inducing ischemia – either in the ischemic organ or in another body site [i.e., remote ischemic conditioning (RIC), e.g., by inflating a cuff around the patient's arm or leg]. The effects of ischemic conditioning have been studied, alone or in combination with revascularization techniques. Based on the timing (before, during, or after ischemia), RIC is classified as pre-, per-/peri-, or post-conditioning, respectively. In this review, we first highlight some pathophysiological and clinical similarities and differences between cardiac and cerebral ischemia. We report evidence that RIC reduces circulating biomarkers of myocardial necrosis, infarct size, and edema, although this effect appears not to translate into a better prognosis. We then review cutting-edge applications of RIC for the treatment of ischemic stroke. We also highlight that, although RIC is a safe procedure that can easily be implemented in hospital and pre-hospital settings, its efficacy in patients with ischemic stroke remains to be proven. We then discuss possible methodological issues of previous studies. We finish by highlighting some perspectives for future research, aimed at increasing the efficacy of ischemic conditioning for improving tissue protection and clinical outcomes, and stratifying myocardial infarction and brain ischemia patients to enhance treatment feasibility.

Systolic blood pressure variability following endovascular thrombectomy and clinical outcome in acute ischemic stroke: A meta-analysis

Blood pressure variability (BPV) has been linked with the outcome of acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). However, the association of the stroke outcome with specific short-term BPV parameters is unclear. We did a systematic literature search for studies published from January 2010 to September 2020. Eligibility criteria included studies with (1) AIS patients treated with EVT with or without thrombolysis; and (2) analysis of the association between short-term systolic BPV parameter and clinical outcomes. Systolic BPV parameters included standard deviation (SD), coefficient of Variation (CoV), successive Variation (SV), and Variation independent of mean. A total of 11 studies were meta-analyzed, comprising 3520 patients who underwent EVT. Lower odds of achieving good functional outcome at 3 months; that is, modified Rankin Scale (mRS) score ≤2 was associated with SD (OR, 0.854; p = .02), CoV (OR, 0.572; p = .04), SV (OR 0.41; p = .00) of systolic blood pressure (SBP). Likewise, higher odds of one-point increase in mRS score was associated with SD (OR 1.42; p = .03), CoV (OR 1.464; p = .00) and SV (OR 2.605; p = .00) of SBP. However, high BPV was not associated with symptomatic intracranial hemorrhage and all-cause mortality at 90 days. The association of BPV and early neurological deterioration was inconclusive. Based on the available studies, short-term systolic BPV is indicative of the clinical outcome of patients following EVT in AIS. Further research should focus on personalized blood pressure management strategies, rather than a one-size-fits-all approach.

Blood Pressure Management After Endovascular Thrombectomy

Endovascular thrombectomy (EVT) has changed the landscape of acute stroke therapy and has become the standard of care for selected patients presenting with anterior circulation large-vessel occlusion (LVO) stroke. Despite successful reperfusion, many patients with LVO stroke do not regain functional independence. Particularly, patients presenting with extremes of blood pressure (BP) or hemodynamic variability are found to have a worse clinical recovery, suggesting blood pressure optimization as a potential neuroprotective strategy. Current guidelines acknowledge the lack of randomized trials to evaluate the optimal hemodynamic management during the immediate post-stroke period. Following reperfusion, lower blood pressure targets may be warranted to prevent reperfusion injury and promote penumbral recovery, but adequate BP targets adjusted to individual patient factors such as degree of reperfusion, infarct size, and overall hemodynamic status remain undefined. This narrative review outlines the physiological mechanisms of BP control after EVT and summarizes key observational studies and clinical trials evaluating post-EVT BP targets. It also discusses novel treatment strategies and areas of future research that could aid in the determination of the optimal post-EVT blood pressure.

Blood Pressure in the First 6 Hours Following Endovascular Treatment for Ischemic Stroke Is Associated With Outcome

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.

Comparison of Outcomes After Treatment of Large Vessel Occlusion in a Critical Care Resuscitation Unit or a Neurocritical Care Unit

BACKGROUND

Mechanical thrombectomy (MT) has become first-line treatment for patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO). Delay in the interhospital transfer (IHT) of patients from referral hospitals to a comprehensive stroke center is associated with worse outcomes. At our academic tertiary care facility in an urban setting, a neurocritical care and emergency neurology unit (NCCU) receives patients with AIS-LVO from outlying medical facilities. When the NCCU is full, patients with AIS-LVO are initially transferred to a critical care resuscitation unit (CCRU). We were interested in quantifying the numbers of AIS-LVO patients treated in those two units and assessing their outcomes. We hypothesized that the CCRU would facilitate an increase in IHTs and provide care comparable to that delivered by the subspecialty NCCU.

METHODS

We conducted a retrospective study of the medical center's prospective stroke registry for adult IHT patients undergoing MT between 01/01/2015 and 12/31/2017. Primary outcome was time from consultation and request for transfer to arrival (Consult-Arrival). Other outcomes of interest were functional independence, defined as 90-day modified Rankin Scale (mRS) score ≤ 2, and 90-day all-cause mortality. Multivariable logistic regression was performed to assess association between clinical factors, mortality, and functional independence.

RESULTS

We analyzed the records of 128 IHT patients: 87 (68%) were admitted to the CCRU, and 41 (32%) to the NCCU. The two groups had similar baseline characteristics (age, National Institutes of Health Stroke Scale score, Alberta Stroke Program Early Computed Tomography scores [ASPECTS]). The median Consult-Arrival time was shorter for CCRU patients than for the NCCU patients (86 [88‒109] vs 100 [77‒127] [p = 0.031]). The 90-day mortality rates (16 vs 30% [p = 0.052]) and the rates having a mRS score ≤ 2 (31 vs 36% [p = 0.59]) were not statistically different. Multivariable logistic regression showed that each minute of delay in the Consult-Arrival time was associated with 2.3% increase in the likelihood of death (OR 1.023; 95% CI 1.003‒1.04 [p = 0.026]), while high thrombolysis in cerebral infarction score was the only factor that was significantly associated with functional independence at 90 days (OR 2.9; 95% CI 1.4‒6.4 [p = 0.006]).

CONCLUSION

The CCRU increased AIS-LVO patients' access to definitive care and reduced their transfer time from outlying medical facilities while achieving outcomes similar to those attained by patients treated in the subspecialty NCCU. We conclude that a resuscitation unit can complement the NCCU to care for patients in the hyperacute phase of AIS-LVO.

European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage

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.

Systemic arterial blood pressure and intracerebral hemorrhage after mechanical thrombectomy in anterior cerebral circulation

The relationship between systemic arterial blood pressure (BP) and intracerebral hemorrhage (ICH) after mechanical thrombectomy (MT) of the cerebral artery remains unclear. This study aimed to determine the effect of BP variables on ICH after MT in patients with acute occlusions of the anterior cerebral circulation. Patients undergoing MT due to acute occlusions of the anterior cerebral circulation were enrolled in this single-center study. Non-invasive BP data following MT were obtained within the first 24 hours, including mean, maximum, minimum, difference between maximum and minimum, SD and coefficient of variation for systolic BP (SBP) and diastolic BP (DBP) and mean arterial pressure. ICH was defined and classified according to the European Cooperative Acute Stroke Study-II. In 164 enrolled patients (median age 65 (IQR 56–75) years; 31.7% female), higher maximum (89.5 mm Hg vs 98.5 mm Hg, p=0.001) and SD (9.8 mm Hg vs 10.9 mm Hg, p=0.038) of DBP were associated with higher risk of ICH. The optimal cut-off values associated with ICH for maximum SBP were 155 mm Hg and for maximum DBP 92.5 mm Hg, respectively. Higher BP within 24 hours after MT in acute occlusions of the anterior cerebral circulation is associated with a greater risk of ICH. More studies are needed to further determine optimal BP goals in the acute phase after MT.

Prolonged Heightened Blood Pressure Following Mechanical Thrombectomy for Acute Stroke is Associated with Worse Outcomes

BACKGROUND

Most data evaluating the relationship of post-mechanical thrombectomy (MT) blood pressure (BP) management and outcomes of patients with large vessel occlusion (LVO) focus on early BP control within the first 24 h. We investigated the correlation of daily BP trends up to the third day following MT with patient outcomes.

METHODS

We retrospectively reviewed our prospectively maintained database for LVO patients treated with MT from February 2015 to December 2017. Recorded BP values for 72 h post-reperfusion were reviewed. Daily peak systolic and diastolic blood pressures (SBP, DBP) were extracted for each day post-procedure. The association and importance between BP increments of 10 mmHg and mortality, hemorrhage, and functional independence (FI = mRS ≤ 2) was analyzed in a multivariable logistic regression and random forest (RF) analyses modeling.

RESULTS

A total of 212 thrombectomies were included. An increase in peak 24-h SBP was independently associated with higher likelihood of symptomatic hemorrhage (OR 1.2, p = 0.048) and decreased functional independence (OR 0.85, p = 0.03). Higher day 2 and day 3 peak SBP was strongly correlated with decreased functional independence and higher mortality. Third day SBP < 140 was independently associated with higher likelihood of functional independence (OR 4.3, p = 0.0004). Post-MT patients with and without functional independence demonstrated a similar relative decrease in peak SBP between the first 2 days following thrombectomy (p = 0.26); however, those without functional independence experienced a significant rebound increase in peak SBP on the third day following MT (mean change from day 2 to 3: FI - 3.5 mmHg, non-FI + 3.9 mmHg; p = 0.005).

CONCLUSION

High daily maximum SBP and a rebound SBP on the third day following MT is independently associated with increased likelihood of functional dependence.

Impact of the Perioperative Blood Pressure on Clinical Outcome after Thrombectomy in Acute Basilar Artery Occlusion

AIM

Optimal blood pressure (BP) management in vertebrobasilar circulation stroke patients undergoing thrombectomy remains undetermined. We aimed to evaluate the impact of perioperative BP on clinical outcome after MT in acute basilar artery occlusion (BAO) patients.

METHODS

We retrospectively analyzed all consecutive patients hospitalized with acute basilar artery occlusion administered endovascular treatment within 24 h from January 2012 to July 2018 in Beijing Tiantan Hospital. BP was measured at regular intervals during the first 24 h after stroke onset, during and after thrombectomy. The clinical outcomes assessed at 3-month follow up were functional independence (mRS score of 0-2) and mortality (mRS score of 6).

RESULTS

Of the 187 treated patients, 157 were male; patient ages were 60±10 years. The median NIHSS on admission was 22. Totally in 179 patients had complete BP level assessment. In these individuals, univariate analysis revealed significant associations of postoperative Max SBP and Max MAP with mortality (all P < 0.05). Multivariate regression analysis also demonstrated that postoperative Max SBP (OR=0.964, 95% CI 0.941 to 0.987, P < 0.003) and Max MAP (OR=0.942, 95% CI 0.907 to 0.979, P < 0.002) were independent predictors of mortality.

CONCLUSIONS

In acute BAO patients administered thrombectomy, Max SBP between 120 and 160 mmHg may be associated with better outcome, with a trend of reduced risk of mortality.

Association of Blood Pressure at Successful Recanalization and Parenchymal Hemorrhage After Mechanical Thrombectomy With General Anesthesia

Background: This study aims to investigate the association between blood pressure (BP) at the time of recanalization and hemorrhagic transformation in large vessel occlusion (LVO) patients following mechanical thrombectomy (MT) with general anesthesia.

Methods: We retrospectively reviewed our data base for patients with acute ischemic stroke acute ischemic stroke (AIS) who received MT between January 2018 and December 2019. The BP at two adjacent time points immediately after successful recanalization was recorded for subsequent calculation of mean BP (BP_mean), maximum BP (BP_max), minimum BP (BP_min), range of BP (BP_range), and standard deviation of SP (BP_SD). Hemorrhagic transformation was identified on 24-h computerized tomography images according to the European Cooperative Acute Stroke Study (ECASS) III trial. We used binary logistic regression analysis to investigate the association of BP parameters and the incidence of parenchymal hemorrhage (PH) and PH-2.

Results: A total of 124 patients with anterior circulation LVO were finally included for analyses. After controlling for intravenous thrombolysis, procedure duration of mechanical thrombectomy, baseline National institutes of Health Stroke Scale (NIHSS), baseline ASPECTS, and number of device passes, the results showed that every increment of 10 mmHg in SBP_range (OR 1.559; 95% CI 1.027–2.365; P = 0.037) and SBP_SD (OR 1.998; 95% CI 1.017–3.925; P = 0.045) were independently associated with PH. After adjustment for intravenous thrombolysis, procedure duration of mechanical thrombectomy, baseline NIHSS, the results showed that every increment of 10 mmHg in SBP_mean (OR 1.973; 95% CI 1.190–3.271; P = 0.008), SBP_max (OR 1.838; 95% CI 1.199 to 2.815; P = 0.005), SBP_range (OR 1.908; 95% CI 1.161–3.136; P = 0.011) and SBP_SD (OR 2.573; 95% CI 1.170–5.675; P = 0.019) were independently associated with PH-2.

Conclusion: Patients with higher systolic BP and variability at the time of successful recanalization were more likely to have PH-2 in LVO patients following MT with general anesthesia.

Blood pressure management after mechanical thrombectomy in stroke patients

Endovascular treatment of acute ischemic stroke (AIS) and mechanical thrombectomy (MT) is proven as a safe and effective novel treatment for emergent large vessel occlusion in the anterior cerebral circulation. However, there are still many unanswered questions on peri and post-procedural management including blood pressure (BP) control. The current guidelines recommend maintaining BP <180/105 mmHg in the first 24 h after MT. However, recent studies suggest that maintaining BP levels at lower levels in the first 24 h after successful revascularization have been associated with favorable functional outcome, reduced mortality rate, and hemorrhagic complications. Not only absolute BP but also its variation in the first 24 h after MT have been associated with neurological outcomes. Evidence on the effect of BP variability (BPV) after MT in AIS even though limited, it does indicate the association of the higher BPV in the first 24 h after MT and poor functional outcomes in AIS. In this review, we will discuss the current literature on BP management in the first 24 h after MT and the impact of BPV in the first 24 h after MT.

Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review

Background and Purpose: Optimal blood pressure (BP) targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) still need to be assessed, especially according to the recanalization status. Facing the lack of randomized controlled trials addressing this question, we performed a systematic review of studies assessing the post-EVT BP impact on functional outcome and symptomatic intracranial hemorrhage (sICH).

Methods: Studies published after January 1, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work.

Results: Five studies were included in the present analysis. Despite a significant heterogeneity among studies which precluded a meta-analysis, systolic BP (SBP) was the most frequently used parameter to describe BP. BP variability (standard deviation, successive variability) after EVT was associated with worse functional outcome, especially in studies without specific BP targets after successful EVT. Lower BP values after successful EVT were associated with lower odds of sICH. Four studies evaluated the post-EVT BP impact on recanalized patients solely, with only one specifically addressing the impact of a TICI 2B vs. 2C. Interestingly, SBP reduction was inversely associated with worse outcomes in TICI 3 patients but not in TICI 2B patients, pointing to the potential value of BP management according to the exact TICI.

Conclusions: BP post-EVT seems to be associated with worse functional outcomes and sICH. However, given the important heterogeneity depicted among the included studies, no decisive conclusion can be made from this systematic review, thus underlying the urgent need of randomized controlled trials evaluating this question.

Comparative effects of intensive-blood pressure versus standard-blood pressure-lowering treatment in patients with severe ischemic stroke in the ENCHANTED trial

OBJECTIVE

Limited data exist on the optimum level of SBP in thrombolyzed patients with acute ischemic stroke (AIS). We aimed to determine the effects of intensive blood pressure (BP) lowering, specifically in patients with severe AIS who participated in the international, Enhanced Control of Hypertension and Thrombolysis Stroke Study.

METHODS

Prespecificed subgroup analyzes of the BP arm of Enhanced Control of Hypertension and Thrombolysis Stroke Study, a multicenter, partial-factorial, open, blinded outcome assessed trial, in which 2227 thrombolysis-eligible and treated AIS patients with elevated SBP (>150 mmHg) were randomized to intensive (target 130-140 mmHg) or guideline-recommended (<180 mmHg) BP management. Severe stroke was defined by computed tomography or magnetic resonance angiogram confirmation of large-vessel occlusion, receipt of endovascular therapy, final diagnosis of large artery atheromatous disease, or high (>10) baseline neurological scores on the National Institutes of Health Stroke Scale. The primary efficacy outcome was death or any disability (modified Rankin scale scores 2-6). The key safety outcome was intracranial hemorrhage (ICH). Treatment effects estimated in logistic regression models are reported as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

There were 1311 patients [mean age 67 years; 37% female; median baseline National Institutes of Health Stroke Scale of 11 (range 6.0-15.0)] with severe AIS. Overall, there was no significant difference in the primary outcome of death or disability. However, intensive BP lowering significantly increased mortality (OR 1.52, 95% CI 1.09-2.13; P = 0.014) compared with guideline BP lowering, despite significantly lowering clinician-reported ICH (OR 0.63, 95% CI 0.43-0.92; P = 0.016).

CONCLUSION

Intensive BP lowering is associated with increased mortality in patients with severe AIS despite lowering the risk of ICH. Further randomized trials are required to provide reliable evidence over the optimum SBP target in the most serious type of AIS.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01422616.

Early blood pressure management for endovascular therapy in acute ischemic stroke: A review of the literature

The perioperative optimal blood pressure targets during mechanical thrombectomy for acute ischemic stroke are uncertain, and randomized controlled trials addressing this issue are lacking. There is still no consensus on the optimal target for perioperative blood pressure in acute ischemic stroke patients with large vessel occlusion. In addition, there are many confounding factors that can influence the outcome including the patient's clinical history and stroke characteristics. We review the factors that have an impact on perioperative blood pressure change and discuss the influence of perioperative blood pressure on functional outcome after mechanical thrombectomy. In conclusion, we suggest that blood pressure should be carefully and flexibly managed perioperatively in patient-received mechanical thrombectomy. Blood pressure changes during mechanical thrombectomy were independently correlated with poor prognosis, and blood pressure should be maintained in a normal range perioperatively. Postoperative blood pressure control is associated with recanalization status in which successful recanalization requires normal range blood pressure (systolic blood pressure 120-140 mmHg), while non-recanalization requires higher blood pressure (systolic blood pressure 160-180 mmHg). The preoperative blood pressure targets for mechanical thrombectomy should be tailored based on the patient's clinical history (systolic blood pressure ≤185 mmHg). Blood pressure should be carefully and flexibly managed intraoperatively (systolic blood pressure 140-180 mmHg) in patient-received endovascular therapy.

Effects of hypertension in patients receiving mechanical thrombectomy: A meta-analysis

BACKGROUND

Available evidence shows conflicting results with regard to a potential detrimental effect of hypertension on clinical outcomes in patients who undergo mechanical thrombectomy (MT). We performed a meta-analysis to evaluate the impact of hypertension on the prognosis of patients with acute ischaemic stroke (AIS) treated by MT.

METHODS

We systematically reviewed previous studies in the PubMed, EMBASE, and Cochrane library databases that reported MT outcomes in AIS patients and their relationships with hypertension or blood pressure. We used a poor outcome (modified Rankin score >2 at 3 months) as the primary end point. Mortality and symptomatic intracranial hemorrhage were the secondary end points. We incorporated a random effect for trials in all models.

RESULTS

Data from 6650 patients in 31 articles that evaluated the effect of hypertension or blood pressure on outcomes after MT were included. Compared with patients without hypertension, patients with hypertension had significantly higher odds of a poor outcome (odds ratio 0.70; 95% confidence interval 0.57-0.85; I = 43%) and higher mortality (odds ratio 1.70; 95% confidence interval 1.26-2.29; I = 33%). Symptomatic intracranial hemorrhage did not differ by patient hypertension status.

CONCLUSIONS

The present study confirms that hypertension and high blood pressure are associated with a poor outcome at 3 months after MT in AIS patients. However, the causal relationship between hypertension and a poor outcome remains undetermined, and further investigations are required to ascertain whether AIS patients receiving MT could benefit from intensive blood pressure control.

Blood Pressure Management Following Acute Ischemic Stroke: A Review of Primary Literature

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.

Association of Blood Pressure With Outcomes in Acute Stroke Thrombectomy

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 (OR_adj) 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 (OR_adj, 1.19 [95% CI,1.00-1.43]; I²=78%, P value for Cochran Q test: 0.001) and symptomatic intracranial hemorrhage (OR_adj, 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 (OR_adj, 0.86 [95% CI, 0.77-0.96]; I²=18%, P value for Cochran Q test: 0.30) and (OR_adj, 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.

Blood Pressure After Endovascular Thrombectomy: Modeling for Outcomes Based on Recanalization Status

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.

Blood pressure reduction and outcome after endovascular therapy with successful reperfusion: a multicenter study

BACKGROUND

Elevated systolic blood pressure (SBP) after mechanical thrombectomy (MT) correlates with worse outcome. However, the association between SBP reduction (SBPr) and outcome after successful reperfusion with MT is not well established.

OBJECTIVE

To investigate the association between SBPr in the first 24 hours after successful reperfusion and the functional and safety outcomes of MT.

METHODS

A multicenter retrospective study, which included 10 comprehensive stroke centers, was carried out. Patients with acute ischemic stroke and anterior circulation large vessel occlusions who achieved successful reperfusion via MT were included. SBPr was calculated using the formula 100×([admission SBP-mean SBP]/admission SBP). Poor outcome was defined as a modified Rankin Scale (mRS) score of 3-6 at 90 days. Safety endpoints included symptomatic intracerebral hemorrhage, mortality, and requirement for hemicraniectomy during admission. A generalized mixed linear model was used to study the association between SBPr and outcomes.

RESULTS

A total of 1361 patients were included in the final analysis. SBPr as a continuous variable was inversely associated with poor outcome (OR=0.97; 95% CI 0.95 to 0.98; p<0.001) but not with the safety outcomes. Subanalysis based on reperfusion status showed that SBPr was associated with lower odds of poor outcome only in patients with complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI 3)) but not in patients with incomplete reperfusion (mTICI 2b). When SBPr was divided into categories (<1%, 1%-10%, 11%-20%, >20%), the rate of poor outcome was highest in the first group.

CONCLUSION

SBPr in the first 24 hours after successful reperfusion was inversely associated with poor outcome. No association between SBPr and safety outcome was found.

Blood Pressure after Endovascular Therapy for Ischemic Stroke (BEST): A Multicenter Prospective Cohort Study

Background and Purpose- To identify the specific post-endovascular stroke therapy (EVT) peak systolic blood pressure (SBP) threshold that best discriminates good from bad functional outcomes (a priori hypothesized to be 160 mm Hg), we conducted a prospective, multicenter, cohort study with a prespecified analysis plan. Methods- Consecutive adult patients treated with EVT for an anterior ischemic stroke were enrolled from November 2017 to July 2018 at 12 comprehensive stroke centers accross the United States. All SBP values within 24 hours post-EVT were recorded. Using Youden index, the threshold of peak SBP that best discriminated primary outcome of dichotomized 90-day modified Rankin Scale score (0-2 versus 3-6) was identified. Association of this SBP threshold with the outcomes was quantified using multiple logistic regression. Results- Among 485 enrolled patients (median age, 69 [interquartile range, 57-79] years; 51% females), a peak SBP of 158 mm Hg was associated with the largest difference in the dichotomous modified Rankin Scale score (absolute risk reduction of 19%). Having a peak SBP >158 mm Hg resulted in an increased likelihood of modified Rankin Scale score 3 to 6 (odds ratio, 2.24 [1.52-3.29], P<0.01; adjusted odds ratio, 1.29 [0.81-2.06], P=0.28, after adjustment for prespecified variables). Conclusions- A peak post-EVT SBP of 158 mm Hg was prospectively identified to best discriminate good from bad functional outcome. Those with a peak SBP >158 had an increased likelihood of having a bad outcome in unadjusted, but not in adjusted analysis. The observed effect size was similar to prior studies. This finding should undergo further testing in a future randomized trial of goal-targeted post-EVT antihypertensive treatment.

Blood Pressure Drop and Penumbral Tissue Loss in Nonrecanalized Emergent Large Vessel Occlusion

Background and Purpose—

For patients with emergent large vessel occlusion who may not benefit from timely recanalization treatment, maintaining adequate cerebral perfusion to prevent penumbral tissue loss is a key therapeutic strategy. Cerebral perfusion should be proportional to systemic blood pressure (BP) due to the loss of autoregulation properties in ischemic brain tissue. We hypothesized that acute fluctuations in BP would lead to aggravated penumbral tissue loss in persistent large vessel occlusion.

Methods—

A total of 80 patients with persistent large vessel occlusion of internal carotid artery or middle cerebral artery admitted within 24 hours after onset, and with a baseline, National Institutes of Health Stroke Scale score ≥4-point were included. Baseline and follow-up (median 88 hours) magnetic resonance images were analyzed, and penumbra was defined as the T max >6 s region excluding baseline infarction. The hypoperfusion intensity ratio (T max >10 s/T max >6 s) was calculated within the penumbra. Penumbral tissue loss (%) was defined as the proportion of follow-up infarct in the penumbra. With serial BP measurements in the first 24 hours (median 29, interquartile range 26–35), BP and BP variability parameters, including BP dropmax (change from local maxima to minima), were calculated and compared. Generalized linear models were applied to examine the association between BP parameters and the penumbral tissue loss.

Results—

The median penumbral volume was 79.3 mL (interquartile range, 38.2–129.6) and median penumbral tissue loss was 36.7% (interquartile range, 12.0–56.1). In a multivariable analysis, systolic BP (SBP) SBP dropmax (β±SE of fourth quartile, 17.82±6.58; P value, 0.01) and diastolic BP (DBP) DBP dropmax (β±SE of fourth quartile, 14.04±6.38; P value, 0.01) were associated with increasing penumbral tissue loss, independently of age, baseline infarction and hypoperfusion intensity ratio. DBP incmax , SBP max , DBP max , SBP max-min , DBP max-min , and most of the DBP variability indices were associated with penumbral tissue loss.

Conclusions—

BP fluctuations, even a brief and drastic BP drop in the first 24 hours, significantly contributed to penumbral tissue loss irrespective of baseline hypoperfusion.

A 10% blood pressure drop from baseline during mechanical thrombectomy for stroke is strongly associated with worse neurological outcomes

Background

Mechanical thrombectomy (MT) for acute ischemic stroke can be performed under local anesthesia, with or without conscious sedation (CS), or under general anesthesia (GA). The hemodynamic consequence of anesthetic drugs may explain why GA may be associated with worse outcomes. We evaluated the association between hypotension duration during MT and the 90 day functional outcome under both anesthetic regimens.

Methods

Patients were included in this retrospective study if they had an ischemic stroke treated by MT under GA or CS. The main exposure variable was the time below 90% of the reference value of arterial pressure measured before MT. The primary outcome was poor functional outcome defined as a 90 day modified Rankin Score ≥3.

Results

371 patients were included in the study. GA was performed in 42%. A linear association between the duration of arterial hypotension and outcome was observed. The odds ratio for poor functional outcome of 10 min under 90% of the baseline mean arterial pressure was 1.13 (95% CI 1.06 to 1.21) without adjustment and 1.11 (95% CI 1.02 to 1.21) after adjustment for confounding factors. The functional outcome was poorer for patients treated under GA compared with CS, but the association with the depth of hypotension remained similar under both conditions.

Conclusion

In this study, we observed a linear association between the duration of hypotension during MT and the functional outcome at 90 days. An aggressive and personalized strategy for the treatment of hypotension should be considered. Further trials should be conducted to address this question.

Effect of short-term blood pressure variability on functional outcome after intra-arterial treatment in acute stroke patients with large-vessel occlusion

Background

Endovascular treatment (EVT) is advocated for acute ischaemic stroke with large-vessel occlusion (LVO), but perioperative periods are challenging. This study investigated the relationship between post-EVT short-term blood pressure variability (BPV) and early outcomes in LVO patients.

Methods

We retrospectively reviewed 72 LVO patients undergoing EVT between June 2015 and June 2018. Hourly systolic and diastolic blood pressures (SBP and DBP, respectively) were recorded in the first 24 h post-EVT. BPV were evaluated as standard deviation (SD), coefficient of variation (CV), and successive variation (SV) separately for SBP and DBP. Functional independence at 3 months was defined as a modified Rankin Scale (mRS) score of 0–2.

Results

For 58.3% patients with favorable outcomes, the median National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT scores on admission were 14 and 8, respectively. The maximum SBP ([154.3 ± 16.8] vs. [163.5 ± 15.6], P = 0.02), systolic CV ([8. 8% ± 2.0%] vs. [11.0% ± 1.8], P < 0.001), SV ([11.4 ± 2.3] vs. [14.6 ± 2.0], P < 0.001), and SD ([10.5 ± 2.4] vs. [13.8 ± 3.9], P < 0.001) were lower in patients with favorable outcomes. On multivariable logistic regression analysis, systolic SV (OR: 4.273, 95% CI: 1.030 to 17.727, P = 0.045) independently predicted unfavorable prognosis. The area under the curve was 0.868 (95% CI: 0.781 to 0.955, P < 0.001), and sensitivity and specificity were 93.3% and 73.8%, respectively, showing excellent predictive value for 3-month poor-outcomes.

Conclusions

Decreased systolic SV following intra-arterial therapies result in favorable outcomes at 3 months. Systolic SV may be a novel predictor of functional prognosis in LVO patients.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12883-019-1457-5.

Is intravenous thrombolysis still necessary in patients who undergo mechanical thrombectomy?

PURPOSE OF REVIEW

To summarize available evidence on the potential utility of pretreatment with intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA) in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO) who are treated with mechanical thrombectomy.

RECENT FINDINGS

Despite theoretical concerns of a higher bleeding risk with IVT pretreatment, there are no data showing increased risk of symptomatic intracerebral hemorrhage (sICH) in patients with LVO receiving bridging therapy (IVT and mechanical thrombectomy) compared with direct mechanical thrombectomy (dMT). Additionally, evidence from observational studies suggest lower rates of infarctions in previously unaffected territories and higher rates of successful reperfusion, with lower number of device passes, in patients receiving bridging therapy. There are substantial discrepancies in studies comparing clinical outcomes between dMT and bridging therapy that are directly related to the inclusion of patients with contraindications to IVT in the dMT group. Ongoing clinical trials will provide definitive answers on the potential additional benefit of IVT in LVO patients receiving mechanical thrombectomy.

SUMMARY

IVT and mechanical thrombectomy are two effective reperfusion therapies that should be used in a swift and noncompeting fashion in AIS patients. AIS patients with LVO and no contraindications for IVT should receive promptly rt-PA bolus followed by immediate initiation of mechanical thrombectomy as indicated by current international recommendations, unless future randomized controlled trials provide evidence to proceed differently.

Acute ischaemic stroke: challenges for the intensivist

PURPOSE

To provide an update about the rapidly developing changes in the critical care management of acute ischaemic stroke patients.

METHODS

A narrative review was conducted in five general areas of acute ischaemic stroke management: reperfusion strategies, anesthesia for endovascular thrombectomy, intensive care unit management, intracranial complications, and ethical considerations.

RESULTS

The introduction of effective reperfusion strategies, including IV thrombolysis and endovascular thrombectomy, has revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. Acute therapeutic efforts are targeted to restoring blood flow to the ischaemic penumbra before irreversible tissue injury has occurred. To optimize patient outcomes, secondary insults, such as hypotension, hyperthermia, or hyperglycaemia, that can extend the penumbral area must also be prevented or corrected. The ICU management of acute ischaemic stroke patients, therefore, focuses on the optimization of systemic physiological homeostasis, management of intracranial complications, and neurological and haemodynamic monitoring after reperfusion therapies. Meticulous blood pressure management is of central importance in improving outcomes, particularly in patients that have undergone reperfusion therapies.

CONCLUSIONS

While consensus guidelines are available to guide clinical decision making after acute ischaemic stroke, there is limited high-quality evidence for many of the recommended interventions. However, a bundle of medical, endovascular, and surgical strategies, when applied in a timely and consistent manner, can improve long-term stroke outcomes.

Association of maximal systolic blood pressure with poor outcome in patients with hyperattenuated lesions on immediate NCCT after mechanical thrombectomy

Background and purpose

This study aimed to investigate the relationship between blood pressure (BP) management and clinical outcome in patients with hyperattenuated lesions on non-contrast CT (NCCT) immediately after mechanical thrombectomy (MT).

Methods

We retrospectively reviewed our prospectively collected cohort for consecutive patients with acute ischemic stroke (AIS) who received MT between October 2013 and July 2018. Hourly systolic BP (SBP) and diastolic BP (DBP) values were recorded for 24 hours following MT, and then maximum SBP (SBPmax) and DBP (DBPmax) values were identified. Poor outcome was defined as 3-month modified Rankin score (mRS) 3–6 and parenchymal hemorrhage (PH) was defined according to the European Cooperative Acute Stroke Study (ECASS) II trial. Associations of BP parameters with poor outcome and PH were determined using binary logistic regression models. Receiver operating characteristics (ROC) curve analysis was used to determine the predictive value of BP.

Results

Initially 262 patients with AIS who received MT were reviewed and 148 patients with hyperattenuated lesions on immediate NCCT were enrolled in the final cohort for analysis. Binary logistic regression showed that every 10 mm Hg increase in SBPmax was independently associated with a poor outcome (OR 1.426; 95% CI 1.095 to 1.855; p=0.008) and PH (OR 1.025; 95% CI 1.005 to 1.480; p=0.044). SBP ≤140 mm Hg during the post-procedural 24-hour period was associated with lower odds of a poor outcome and PH compared with the other group.

Conclusions

Control of maximal SBP within 24 hours might be related to a low rate of PH and poor outcome in patients with hyperattenuated lesions on immediate NCCT after intervention.

Blood pressure variability and hemorrhagic transformation in patients with successful recanalization after endovascular recanalization therapy: A retrospective observational study

OBJECTIVE

Although blood pressure (BP) variability has been regarded as a risk factor for hemorrhagic transformation (HTF) after intravenous thrombolysis, its effect on HTF after endovascular recanalization therapy (ERT) remains to be elucidated. We aimed to study the relationship between BP variability and symptomatic intracerebral hemorrhage (sICH) after successful recanalization with ERT.

METHODS

A total of 211 patients with acute ischemic stroke and successful recanalization (thrombolysis in cerebral infarction 2b or 3) after ERT were included between January 2013 and May 2017. The BP data following ERT was obtained over the first 24 hours using parameters including mean, maximum, minimum, difference between maximum and minimum, standard deviation, coefficient of variation, successive variations, and time rate (TR) of BP variation for systolic BP (SBP) and diastolic BP. sICH was defined as parenchymal hemorrhage type 2 with neurological deterioration of 4 points of more on the National Institute of Health Stroke Scale.

RESULTS

Among the included patients, 20 (9.5%) developed sICH after successful ERT. The parameters linked with BP fluctuation over time were significantly related to sICH. After adjusting for confounders, the TR of SBP (per 0.1 mmHg/min increase) variation was independently associated with sICH (odds ratio = 1.71, 95% confidence interval = 1.013-2.886).

INTERPRETATION

Time-related BP variability in the first 24 hours following successful ERT was more correlated with sICH than other absolute BP levels. This suggests that maintaining a stable BP may be an important factor in preventing sICH after successful ERT. Ann Neurol 2019;85:574-581.

Impact of blood pressure levels within first 24 hours after mechanical thrombectomy on clinical outcome in acute ischemic stroke patients

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.

The safety of post-operative elevation of mean arterial blood pressure following brain tumor resection

We demonstrate the safety of artificially elevating the mean arterial blood pressure (MAP) greater than 85 mmHg or 10% above the mean MAP in patients with underlying hypertension during the acute post-operative period in patients undergoing surgery for resection of brain tumors. A retrospective review was undertaken of all patients undergoing surgery by the senior author between 2013 and 2018. Patients who underwent MAP therapy were analyzed for hemorrhagic and cardiac complications. A total of 1162 of 2270 post-operative brain tumor patients underwent MAP therapy after surgery for a minimum of 24 h post-operatively. Of these, 7/1162 (0.6%) patients experienced intra-cavitary hemorrhage within 5 days of surgery. Two of 7 (29%) patients were diagnosed with venous infarction. One of 7 (14%) patients experienced post-operative, intra-cavitary hemorrhage prior to the initiation of MAP therapy. The remaining 4/1162 (0.35%) patients experienced intra-cavitary hemorrhage post-operatively without clear etiology. In assessing cardiac outcomes, 2/1162 patients (0.2%) experienced elevated troponin levels. No patient demonstrated significant cardiac related morbidity or mortality within this cohort. Post-operative MAP therapy with a goal of maintaining MAP greater than 85 mmHg or 10% above the mean MAP in patients with underlying hypertension appears to be a safe intervention in brain tumor patients for at least 24 h in the post-operative period.