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Luo C, Nguyen TN, Li R, Tao C, Jing X, Xu P, Wang L, Wang A, Gao F, Cai M, Zhang K, Chen M, Jiang X, Shen N, Abdalkader M, Michel P, Saver JL, Nogueira RG, Liu X, Hu W. Association Between Collateral Status, Blood Pressure During Thrombectomy, and Clinical Outcomes in Patients With Basilar Artery Occlusion. Neurology 2025; 104:e213504. [PMID: 40184589 DOI: 10.1212/wnl.0000000000213504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Accepted: 02/06/2025] [Indexed: 04/06/2025] Open
Abstract
BACKGROUND AND OBJECTIVES We investigated the relationship between intraprocedural blood pressure (BP) and clinical outcomes in patients with basilar artery occlusion (BAO) undergoing endovascular treatment (EVT), exploring whether it is modifiable by collateral status. METHODS Patient data from the Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION) randomized trial were analyzed for those with BAO who received EVT. Intraprocedural BP data were extracted, with collateral status assessed using the Basilar Artery on CT Angiography (BATMAN) score (BATMAN score ≥7 favorable collateral status, <7 unfavorable). Associations between BP parameters and outcomes were assessed using multivariable logistic regression and restricted cubic splines. The effect modification was assessed using an interaction term between BP parameters and collateral status. The primary outcome was a favorable outcome defined by a modified Rankin Scale (mRS) score of 0-3 at 90 days. RESULTS There were 212 patients included (median age 68 years, 32.1% female). Restricted cubic spline analysis showed that the SDs of systolic BP (SBP) and mean arterial pressure (MAP) had J-shaped relationships with favorable outcome (p for nonlinearity = 0.004 and <0.001, respectively), with inflection points at 12 and 8 mm Hg, respectively. Multivariable logistic regression showed that MAP of 80-110 mm Hg (adjusted odds ratio [aOR] 3.00, 95% CI 1.46-6.35) and MAP SD <8 mm Hg (aOR 2.28, 95% CI 1.24-4.25) were associated with favorable outcome. Significant interactions with collateral status were observed for MAP SD <8 mm Hg, SBP SD <12 mm Hg, MAP drop >20%, and minimum MAP and SBP (all pinteraction < 0.05). After Holm-Bonferroni correction, only the interaction between collateral status and MAP <80 mm Hg remained significant (corrected pinteraction = 0.036). In patients with unfavorable collateral status, MAP <80 mm Hg was associated with decreased probability of favorable outcome (aOR 0.04, 95% CI 0.00-0.21) while this association was not observed in patients with favorable collaterals. DISCUSSION For patients with BAO undergoing EVT, intraprocedural MAP between 80 and 110 mm Hg was associated with favorable outcome while MAP <80 mm Hg was associated with a lower probability of favorable outcome, especially in patients with unfavorable collateral status.
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Affiliation(s)
- Cong Luo
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Rui Li
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Chunrong Tao
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Xiaozhong Jing
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Pengfei Xu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Li Wang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Anmo Wang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Feiyang Gao
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Ming Cai
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Keyi Zhang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Min Chen
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Xia Jiang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Nan Shen
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Switzerland
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; and
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, PA
| | - Xinfeng Liu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
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Liang F, Zhang K, Wu Y, Wang X, Hou X, Yu Y, Wang Y, Wang M, Pan Y, Huo X, Han R, Miao Z. Anaesthesia modality on endovascular therapy outcomes in patients with large infarcts: a post hoc analysis of the ANGEL-ASPECT trial. Stroke Vasc Neurol 2025; 10:e003320. [PMID: 39160092 DOI: 10.1136/svn-2024-003320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/30/2024] [Indexed: 08/21/2024] Open
Abstract
OBJECTIVES Endovascular therapy (EVT) now penetrates the once obscure realm of large infarct core volume acute ischaemic stroke (LICV-AIS). This research aimed to investigate the potential correlation between different anaesthetic approaches and post-EVT outcomes in LICV-AIS patients. METHODS Between October 2020 and May 2022, the China ANGEL-Alberta Stroke Programme Early CT Score (ASPECT) trial studied patients with LICV-AIS, randomly assigning them to the best medical management (BMM) or BMM with EVT. This post hoc subgroup analysis categorised subjects receiving BMM with EVT into general anaesthesia (GA) and non-GA groups based on anaesthesia type. We applied multivariable logistic regression to evaluate the relationship between anaesthesia during EVT and patient functional outcomes, as measured by the modified Rankin scale (mRS), in addition to the occurrence of complications. Further adjustment for selection bias was achieved through propensity score matching (PSM). RESULTS In total, 230 patients with LICV-AIS were enrolled (GA 84 vs Non-GA 146). No significant difference was observed between the two groups in terms of the proportion of patients who achieved an mRS score of 0-2 at 90 days (27.4% for the GA group vs 31.5% for the non-GA group, p=0.51). However, the GA group had significantly longer median surgical times (142 min vs 122 min, p=0.03). Furthermore, GA was associated with an increased risk of postoperative pneumonia (adjusted OR 2.03, 95% CI 1.04 to 3.98). The results of PSM analysis agreed with the results of the multivariate regression analysis. No significant difference in intracranial haemorrhage incidence or mortality rate was observed between the groups. CONCLUSION This post hoc analysis of subgroups of the ANGEL-ASPECT trial suggested that there may be no significant association between the choice of anaesthesia and neurological outcomes in LICV-AIS patients. However, compared with non-GA, GA prolongs the duration of EVT and is associated with a greater postoperative pneumonia risk. TRIAL REGISTRATION NUMBER NCT04551664.
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Affiliation(s)
- Fa Liang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kangda Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxuan Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinyan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan Hou
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yun Yu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunzhen Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mengxing Wang
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaochuan Huo
- Department of Neurology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Ball JD, Panerai RB, Henstock T, Minhas JS. Arterial blood pressure monitoring in stroke cohorts: the impact of reduced sampling rates to optimise remote patient monitoring. Blood Press Monit 2024; 29:290-298. [PMID: 39570715 DOI: 10.1097/mbp.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2024]
Abstract
OBJECTIVE Remote patient monitoring (RPM) beat-to-beat blood pressure (BP) provides an opportunity to measure poststroke BP variability (BPV), which is associated with clinical stroke outcomes. BP sampling interval (SI) influences ambulatory BPV, but RPM BP SI optimisation research is limited. SI and RPM device capabilities require compromises, meaning SI impact requires investigation. Therefore, this study assessed healthy and stroke subtype BPV via optimised BP sampling, aiding sudden BP change identification and potentially assisting cardiovascular event (recurrent stroke) prediction. METHODS Leicester Cerebral Haemodynamic Database ischaemic [acute ischaemic stroke (AIS), n = 68] and haemorrhagic stroke (intracerebral haemorrhage, n = 12) patient and healthy control (HC, n = 40) baseline BP data were analysed. Intrasubject and interpatient SD (SD i /SD p ) represented individual/population variability with synthetically altered SIs. Matched-filter approaches using cross-correlation function detected sudden BP changes. RESULTS At SIs between 1 and 180 s, SBP and DBP SD i staticised while SD p increased at SI < 30 s. Mean BP and HR SD i and SD p increased at SI < 60s. AIS BPV, normalised to SI1s, increased at SI30s (26%-131%) and SI120s (1%-274%). BPV increased concomitantly with SI. Cross-correlation analysis showed HC and AIS BP sudden change detection accuracy reductions with increasing SI. Positive BP deviation detection fell 48.48% (SI10s) to 78.79% (SI75s) in HC and 67.5% (SI10s) to 100% (SI75s) in AIS. Negative BP deviation detection fell 50% (SI10s) to 82.35% (SI75s) in HC and 52.27% (SI10s) to 95.45% (SI75s) in AIS. CONCLUSION Sudden BP change detection and BPV are relatively robust to SI increases within certain limits, but accuracy reductions generate unacceptable estimates, considerable within RPM device design. This research warrants further SI optimisation.
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Affiliation(s)
- James D Ball
- Department of Cardiovascular Sciences, University of Leicester
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester
| | | | - Jatinder S Minhas
- Department of Cardiovascular Sciences, University of Leicester
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester
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Kim Y, Mattos MK, Esquivel JH, Davis EM, Logan J. Sleep and blood pressure variability: A systematic literature review. Heart Lung 2024; 68:323-336. [PMID: 39217647 DOI: 10.1016/j.hrtlng.2024.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 08/21/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Blood pressure variability (BPV) is a prognostic marker of cardiovascular disease (CVD). Sleep is recognized as a significant risk factor for CVD; however, little is known about the relationship between sleep characteristics and BPV. OBJECTIVE In this systematic review, we aimed to (1) describe methods used to measure BPV and sleep and (2) describe the current evidence in the literature on the association between sleep and BPV. METHODS A systematic search was conducted using the search terms "sleep" AND ("blood pressure variability" OR "ambulatory blood pressure monitor") in CINAHL, PubMed, Web of Science, and PsycINFO databases. RESULTS Twenty-two studies were included in this systematic review. Sleep was measured using various methods, including polysomnography, actigraphy, sleep diaries, and questionnaires, while BPV was measured over various time intervals using different monitoring devices such as a beat-to-beat blood pressure (BP) monitoring device, a 24-h ambulatory BP monitor, or an automatic upper arm BP monitor. The studies demonstrated mixed results on the associations between sleep parameters (sleep quality, architecture, and duration) and increased BPV. CONCLUSIONS Although the mechanisms that explain the relationship between sleep and BPV are still unclear, accumulating evidence suggests potential associations between increased BPV with poor sleep quality and longer sleep duration. Given the recent development of sleep and BP monitoring technologies, further research is warranted to assess sleep and BPV under free-living conditions. Such studies will advance our understanding of complex interactions between sleep and CVD risk.
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Affiliation(s)
- Yeonsu Kim
- University of Virginia School of Nursing, 225 Jeanette Lancaster Way, Charlottesville, VA, 22903, USA.
| | - Meghan Kathleen Mattos
- University of Virginia School of Nursing, 5012 McLeod Hall, 202 Jeanette Lancaster Way, Charlottesville, VA, 22903, USA
| | - Jill Howie Esquivel
- University of California San Francisco School of Nursing, 2 Koret Way, San Francisco, CA, 94143, USA
| | - Eric M Davis
- Department of Medicine, University of Virginia, 1222 Jefferson Park Ave, Charlottesville, VA, 22903, USA
| | - Jeongok Logan
- University of Virginia School of Nursing, 4011 McLeod Hall, 202 Jeanette Lancaster Way, Charlottesville, VA, 22903, USA
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Cho H, Kim T, Lee Y, Kim D, Bae H. Overall and linked blood pressure variabilities in the first 24 hours and mortality after spontaneous intracerebral hemorrhage: a retrospective study of 1,036 patients. Anesth Pain Med (Seoul) 2024; 19:302-309. [PMID: 39512052 PMCID: PMC11558055 DOI: 10.17085/apm.24039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 08/08/2024] [Accepted: 08/12/2024] [Indexed: 11/15/2024] Open
Abstract
BACKGROUND This study aims to establish the individual contributions of blood pressure variability (BPV) indexes, categorized into overall and linked variability, to mortality following intracerebral hemorrhage (ICH) by examining the risk factors. METHODS Patients with spontaneous ICH (n = 1,036) were identified with valid blood pressures (BP) from the first 24-h systolic BP records in the Medical Information Mart for Intensive Care IV version 2.2 database (MIMIC IV). Information on the baseline characteristics, including age, sex, initial Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) scores, ICH location, Charlson comorbidity index score, and presence of diabetes with or without complications, were collected. Three indexes of BPV-range, standard deviation (SD), and generalized BPV (GBPV)-were calculated using the first 24-h systolic BPs. An automated stepwise variable-selection procedure was used to develop the final logistic model for predicting in-hospital mortality. RESULTS Out of 1,036 patients, 802 (77.4%) survived and were discharged after spontaneous ICH. Factors associated with mortality included age; male sex; ICH in the brainstem, ventricle, or multiple locations; low GCS score (< 9); high NIHSS score (> 20); and diabetes with complications. Mean systolic BP, SD, and GBPV were also linked to mortality. Higher GBPV notably increased the risk of in-hospital death, with an odds ratio of 3.21 (95% confidence interval, 2.10 to 4.97) for every + 10 mmHg/h change in GBPV. CONCLUSIONS This study underscores the additional impact of GBPV, herein linked to BPV, on mortality following ICH, providing further insights into the management of blood pressure in the early stages of ICH treatment.
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Affiliation(s)
- Hangyul Cho
- Department of Anesthesiology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Taehoon Kim
- Department of Anesthesiology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Younsuk Lee
- Department of Anesthesiology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Dawoon Kim
- Department of Anesthesiology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Hansu Bae
- Department of Anesthesiology, Dongguk University Ilsan Hospital, Goyang, Korea
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Yilmaz G, Alexander JS. Impaired Peripheral Vascular Function Following Ischemic Stroke in Mice: Potential Insights into Blood Pressure Variations in the Post-Stroke Patient. PATHOPHYSIOLOGY 2024; 31:488-501. [PMID: 39311310 PMCID: PMC11417821 DOI: 10.3390/pathophysiology31030036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/14/2024] [Accepted: 08/29/2024] [Indexed: 09/26/2024] Open
Abstract
High systolic blood pressure and increased blood pressure variability after the onset of ischemic stroke are associated with poor clinical outcomes. One of the key determinants of blood pressure is arteriolar size, determined by vascular smooth muscle tone and vasodilatory and vasoconstrictor substances that are released by the endothelium. The aim of this study is to outline alterations in vasomotor function in isolated peripheral arteries following ischemic stroke. The reactivity of thoracic aortic segments from male C57BL/6 mice to dilators and constrictors was quantified using wire myography. Acetylcholine-induced endothelium-dependent vasodilation was impaired after ischemic stroke (LogIC50 Sham = -7.499, LogIC50 Stroke = -7.350, p = 0.0132, n = 19, 31 respectively). The vasodilatory responses to SNP were identical in the isolated aortas in the sham and stroke groups. Phenylephrine-induced vasoconstriction was impaired in the aortas isolated from the stroke animals in comparison to their sham treatment counterparts (Sham LogEC50= -6.652 vs. Stroke LogEC50 = -6.475, p < 0.001). Our study demonstrates that 24 h post-ischemic stroke, peripheral vascular responses are impaired in remote arteries. The aortas from the stroke animals exhibited reduced vasoconstrictor and endothelium-dependent vasodilator responses, while the endothelium-independent vasodilatory responses were preserved. Since both the vasodilatory and vasoconstrictor responses of peripheral arteries are impaired following ischemic stroke, our findings might explain increased blood pressure variability following ischemic stroke.
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Affiliation(s)
- Gokhan Yilmaz
- Molecular Cellular and Biomedical Sciences, CUNY School of Medicine, New York, NY 10031, USA
| | - Jonathan Steven Alexander
- Molecular & Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
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Ren J, Qu Y, Gao Y, Ma H, Zhang P, Guo Z, Yang Y. Beat-to-Beat Blood Pressure Variability Within 24 Hours of Ischemic Stroke Onset: A Potential Predictor of Functional Prognosis. J Am Heart Assoc 2024; 13:e034575. [PMID: 39023075 PMCID: PMC11964061 DOI: 10.1161/jaha.124.034575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/25/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Beat-to-beat blood pressure variability (BPV) is based on each heartbeat and represents a dynamic equilibrium process modulated by artery and cardiac involvement of pressure-receptive reflexes. To date, there remains a lack of prospective studies illustrating the clinical value of beat-to-beat BPV within 24 hours of acute ischemic stroke onset. METHODS AND RESULTS This study prospectively monitored beat-to-beat blood pressure and heart rate in patients with acute ischemic stroke within 24 hours of onset using a noninvasive plethysmograph and calculated beat-to-beat BPV, heart rate variability, and the cross-correlation baroreflex sensitivity. A modified Rankin Scale score of ≥2 at 90 days was defined as an unfavorable prognosis. Multivariate logistic regression was performed, and the nomogram model was developed by adding the beat-to-beat BPV to the traditional model for predicting prognosis. Beat-to-beat BPV increased significantly in the unfavorable outcome group (P<0.05) compared with that in the favorable outcome group, whereas no difference was observed in beat-to-beat heart rate variability and cross-correlation baroreflex sensitivity between both groups (P>0.05). Furthermore, beat-to-beat BPV within 24 hours of acute ischemic stroke onset was independently associated with unfavorable outcome at 90 days (P<0.005). The addition of beat-to-beat BPV to the traditional model for predicting prognosis enhanced the area under the receiver operating characteristic curve from 0.816 to 0.830. CONCLUSIONS Increased beat-to-beat BPV within 24 hours of acute ischemic stroke onset was independently associated with a poor prognosis at 90 days and may be a potential predictor for discriminating unfavorable prognosis.
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Affiliation(s)
- Jia‐Xin Ren
- Stroke Center, Department of NeurologyThe First Hospital of Jilin UniversityChang ChunChina
| | - Yang Qu
- Stroke Center, Department of NeurologyThe First Hospital of Jilin UniversityChang ChunChina
| | - Yi Gao
- Stroke Center, Department of NeurologyThe First Hospital of Jilin UniversityChang ChunChina
| | - Hong‐Yin Ma
- Stroke Center, Department of NeurologyThe First Hospital of Jilin UniversityChang ChunChina
| | - Peng Zhang
- Stroke Center, Department of NeurologyThe First Hospital of Jilin UniversityChang ChunChina
| | - Zhen‐Ni Guo
- Stroke Center, Department of NeurologyThe First Hospital of Jilin UniversityChang ChunChina
- Neuroscience Research Center, Department of NeurologyThe First Hospital of Jilin UniversityChang ChunChina
| | - Yi Yang
- Stroke Center, Department of NeurologyThe First Hospital of Jilin UniversityChang ChunChina
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8
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Cui Y, Ning YX, Cai JR, Zhang NN, Chen HS. Association of systolic blood pressure variability with remote ischemic conditioning in acute ischemic stroke. Sci Rep 2024; 14:15562. [PMID: 38971863 PMCID: PMC11227509 DOI: 10.1038/s41598-024-66572-2] [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: 12/25/2023] [Accepted: 07/02/2024] [Indexed: 07/08/2024] Open
Abstract
Systolic blood pressure variability (SBPV) is associated with outcome in acute ischemic stroke. Remote ischemic conditioning (RIC) has been demonstrated to be effective in stroke and may affect blood pressure. Relationship between SBPV and RIC treatment after stroke warrants investigation. A total of 1707 patients from per-protocol analysis set of RICAMIS study were included. The SBPV was calculated based on blood pressure measured at admission, Day 7, and Day 12. (I) To investigate the effect of SBPV on efficacy of RIC in stroke, patients were divided into High and Low categories in each SBPV parameter. Primary outcome was excellent functional outcome at 90 days. Compared with Control, efficacy of RIC in each category and interaction between categories were investigated. (II) To investigate the effect of RIC treatment on SBPV, SBPV parameters were compared between RIC and Control groups. Compared with Control, a higher likelihood of primary outcome in RIC was found in high category (max-min: adjusted risk difference [RD] = 7.2, 95% CI 1.2-13.1, P = 0.02; standard deviation: adjusted RD = 11.5, 95% CI 1.6-21.4, P = 0.02; coefficient of variation: adjusted RD = 11.2, 95% CI 1.4-21.0, P = 0.03). Significant interaction of RIC on outcomes were found between High and Low standard deviations (adjusted P < 0.05). No significant difference in SBPV parameters were found between treatment groups. This is the first report that Chinese patients with acute moderate ischemic stroke and presenting with higher SBPV, who were non-cardioemoblic stroke and not candidates for intravenous thrombolysis or endovascular therapy, would benefit more from RIC with respect to functional outcomes at 90 days, but 2-week RIC treatment has no effect on SBPV during hospital.
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Affiliation(s)
- Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Yue-Xin Ning
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, China
- Department of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Ji-Ru Cai
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, China
- Department of Neurology, Postgraduate Training Base of Jinzhou Medical University in the General Hospital of Northern Theater Command, Shenyang, China
| | - Nan-Nan Zhang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, China.
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9
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Robbe MMQ, Pinckaers FME, Santegoeds RGC, Bos MJ, van Oostenbrugge RJ, van Zwam WH, Staals J, Postma AA. Procedural blood pressure and contrast extravasation on dual energy computed tomography after endovascular stroke treatment. J Stroke Cerebrovasc Dis 2024; 33:107673. [PMID: 38458504 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/11/2023] [Accepted: 03/04/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Blood brain barrier disruption (BBBD) can be visualized by contrast extravasation (CE) after endovascular treatment (EVT) in patients with acute ischemic stroke. Elevated blood pressure is a risk factor for BBBD. However, the association between procedural blood pressure and CE post-EVT is unknown. METHODS In this single-center retrospective study, we analyzed 501 eligible patients who received a dual energy CT (DECT) immediately post-EVT for acute ischemic stroke. Procedural blood pressure values (SBPmean, SBPmax, SBPmax-min, and MAPmean) were collected. CE was quantified by measuring the maximum parenchymal iodine concentration on DECT iodine overlay map reconstructions. As a measure for the extent of BBBD, we created CE-ASPECTS by deducting one point per hyperdense ASPECTS region on iodine overlay maps. The association between blood pressure and CE was assessed using multivariable linear regression. RESULTS The procedural SBPmean, SBPmax, and MAPmean were 150 ± 26 mmHg, 173 ± 29 mmHg, and 101 ± 17 mmHg, respectively. The median maximum iodine concentration on post-EVT DECT was 1.2 mg/ml (IQR 0.7-2.0), and median CE-ASPECTS was 8 (IQR 5-11). The maximum iodine concentration was not associated with blood pressure. SBPmean, SBPmax, and MAPmean were significantly associated with CE-ASPECTS (per 10 mmHg, β = -0.2, 95 % CI -0.31 to -0.09, β = -0.15, 95 % CI -0.25 to -0.06, β = -0.33, 95 % CI -0.49 to -0.17, respectively). CONCLUSION In acute ischemic stroke patients undergoing EVT, particularly in patients achieving successful recanalization, SBPmean, SBPmax, and MAPmean are associated with the extent of BBBD on immediate post-EVT DECT, but not with maximum iodine concentration.
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Affiliation(s)
- M M Q Robbe
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - F M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands
| | - R G C Santegoeds
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - M J Bos
- Departments of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - R J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - W H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands
| | - J Staals
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - A A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; School for Mental Health and Sciences (MHENS), Maastricht University, Maastricht, the Netherlands
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10
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Xu D, Qi P, Liu P, Yang H, Ye G, Shan D, Lei S, Yang G, Ding J, Liang H, Qi H, Wang D, Lu J. Machine learning models reveal the critical role of nighttime systolic blood pressure in predicting functional outcome for acute ischemic stroke after endovascular thrombectomy. Front Neurol 2024; 15:1405668. [PMID: 38784914 PMCID: PMC11112097 DOI: 10.3389/fneur.2024.1405668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
Background Blood pressure (BP) is a key factor for the clinical outcomes of acute ischemic stroke (AIS) receiving endovascular thrombectomy (EVT). However, the effect of the circadian pattern of BP on functional outcome is unclear. Methods This multicenter, retrospective, observational study was conducted from 2016 to 2023 at three hospitals in China (ChiCTR2300077202). A total of 407 patients who underwent endovascular thrombectomy (EVT) and continuous 24-h BP monitoring were included. Two hundred forty-one cases from Beijing Hospital were allocated to the development group, while 166 cases from Peking University Shenzhen Hospital and Hainan General Hospital were used for external validation. Postoperative systolic BP (SBP) included daytime SBP, nighttime SBP, and 24-h average SBP. Least absolute shrinkage and selection operator (LASSO), support vector machine-recursive feature elimination (SVM-RFE), Boruta were used to screen for potential features associated with functional dependence defined as 3-month modified Rankin scale (mRS) score ≥ 3. Nine algorithms were applied for model construction and evaluated using area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy. Results Three hundred twenty-eight of 407 (80.6%) patients achieved successful recanalization and 182 patients (44.7%) were functional independent. NIHSS at onset, modified cerebral infarction thrombolysis grade, atrial fibrillation, coronary atherosclerotic heart disease, hypertension were identified as prognostic factors by the intersection of three algorithms to construct the baseline model. Compared to daytime SBP and 24-h SBP models, the AUC of baseline + nighttime SBP showed the highest AUC in all algorithms. The XGboost model performed the best among all the algorithms. ROC results showed an AUC of 0.841 in the development set and an AUC of 0.752 in the validation set for the baseline plus nighttime SBP model, with a brier score of 0.198. Conclusion This study firstly explored the association between circadian BP patterns with functional outcome for AIS. Nighttime SBP may provide more clinical information regarding the prognosis of patients with AIS after EVT.
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Affiliation(s)
- Dingkang Xu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Peng Qi
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Peng Liu
- Department of Neurosurgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Hongchun Yang
- Department of Neurosurgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Gengfan Ye
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo University, Ningbo, Zhejiang, China
| | - Dezhi Shan
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Shixiong Lei
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Guozheng Yang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Junqing Ding
- Neurology Department, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hui Liang
- Department of Neurology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Hainan Province Clinical, Medical Center and Hainan Academician Innovation Platform, Haikou, China
| | - Hui Qi
- Department of Neurosurgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Daming Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Jun Lu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
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11
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Medicherla C, Pashun R, Al-Mufti F. Review of Cerebral Collateral Circulation and Insight into Cardiovascular Strategies to Limit Collateral Damage in Ischemic Stroke. Cardiol Rev 2024; 32:188-193. [PMID: 37729598 DOI: 10.1097/crd.0000000000000614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Cerebral collateral circulation is a dynamic and adaptive process by which alternative vascular pathways supply perfusion to ischemic brain tissue in the event of an arterial occlusion. This complicated network of blood vessels that acts as a natural bypass plays a pivotal role in stroke pathophysiology and has become a key area of study given its significance in stroke treatment and patient outcomes. In this review, we will study the factors influencing the formation, recruitment, and endurance of collateral vessels; discuss imaging modalities for quantitative and qualitative assessment of this network; explore the role of collaterals in stroke management; and highlight several cardiovascular strategies to minimize damage to collaterals and optimize stroke outcomes.
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Affiliation(s)
| | - Raymond Pashun
- Department of Cardiology, New York University Langone Health, New York, NY
| | - Fawaz Al-Mufti
- Department of Neurology, Neurosurgery, and Radiology, New York Medical College, Valhalla, NY
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12
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Yang LN, Sun Y, Wang YZ, Wang J, Qi YS, Mu SS, Liu YP, Zhang ZQ, Chen ZM, Wang XJ, Xie WX, Wei CW, Wang Y, Wu AS. Effect of Postoperative Prolonged sedation with Dexmedetomidine after successful reperfusion with Endovascular Thrombectomy on long-term prognosis in patients with acute ischemic stroke (PPDET): study protocol for a randomized controlled trial. Trials 2024; 25:166. [PMID: 38439027 PMCID: PMC10913237 DOI: 10.1186/s13063-024-08015-x] [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: 05/29/2023] [Accepted: 02/23/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is a standard treatment for acute ischemic stroke (AIS) with large vessel occlusion. Hypertension and increased blood pressure variability within the first 24 h after successful reperfusion are related to a higher risk of symptomatic intracerebral hemorrhage and higher mortality. AIS patients might suffer from ischemia-reperfusion injury following reperfusion, especially within 24 h. Dexmedetomidine (DEX), a sedative commonly used in EVT, can stabilize hemodynamics by inhibiting the sympathetic nervous system and alleviate ischemia-reperfusion injury through anti-inflammatory and antioxidative properties. Postoperative prolonged sedation for 24 h with DEX might be a potential pharmacological approach to improve long-term prognosis after EVT. METHODS This single-center, open-label, prospective, randomized controlled trial will include 368 patients. The ethics committee has approved the protocol. After successful reperfusion (modified thrombolysis in cerebral infarction scores 2b-3, indicating reperfusion of at least 50% of the affected vascular territory), participants are randomly assigned to the intervention or control group. In the intervention group, participants will receive 0.1~1.0 μg/kg/h DEX for 24 h. In the control group, participants will receive an equal dose of saline for 24 h. The primary outcome is the functional outcome at 90 days, measured with the categorical scale of the modified Rankin Scale, ranging from 0 (no symptoms) to 6 (death). The secondary outcome includes (1) the changes in stroke severity between admission and 24 h and 7 days after EVT, measured by the National Institute of Health Stroke Scale (ranging from 0 to 42, with higher scores indicating greater severity); (2) the changes in ischemic penumbra volume/infarct volume between admission and 7 days after EVT, measured by neuroimaging scan; (3) the length of ICU/hospital stay; and (4) adverse events and the all-cause mortality rate at 90 days. DISCUSSION This randomized clinical trial is expected to verify the hypothesis that postoperative prolonged sedation with DEX after successful reperfusion may promote the long-term prognosis of patients with AIS and may reduce the related socio-economic burden. TRIAL REGISTRATION ClinicalTrials.gov NCT04916197. Prospectively registered on 7 June 2021.
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Affiliation(s)
- Li-Na Yang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yi Sun
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yu-Zhu Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Jing Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yi-Sha Qi
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Shan-Shan Mu
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yun-Peng Liu
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Zi-Qing Zhang
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Zi-Mo Chen
- Department of Neurology, Beijing Tian-tan Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Xiao-Jie Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Wu-Xiang Xie
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, 101125, People's Republic of China
| | - Chang-Wei Wei
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China.
| | - Yang Wang
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China.
| | - An-Shi Wu
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China.
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Chen Y, Ma Y, Qin J, Wei X, Yang Y, Yuan Y, Yan F, Huo X, Han L. Blood pressure variability predicts poor outcomes in acute stroke patients without thrombolysis: a systematic review and meta-analysis. J Neurol 2024; 271:1160-1169. [PMID: 38036920 DOI: 10.1007/s00415-023-12054-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Stroke is a significant medical condition, and blood pressure stands out as the most prevalent treatable risk factor associated with it. Researches link blood pressure variability (BPV) with stroke; however, the specific relationship between with the outcomes of stroke patients remains unclear. As blood pressure variability and mean blood pressure are interrelated, it remains uncertain whether BPV adds additional information to understanding the outcome of acute stroke patients. OBJECTIVE To systematically review studies investigating the association between blood pressure variability and prognosis in acute stroke patients. METHODS Embase, PubMed, Web of Science, and the Cochrane Library were searched for English language full-text articles from the inception to 1 January 2023. Stroke patients aged ≥ 18 years were included in this analysis. Stroke types were not restricted. RESULTS This meta-analysis shows that higher systolic blood pressure variability is linked to a higher risk of poor outcome, including function disability, mortality, early neurological deterioration, and stroke recurrence, among acute stroke patients without thrombolysis. A higher diastolic blood pressure variability is linked with to a higher risk of mortality and functional disability. CONCLUSIONS This review reveals that blood pressure variability is a novel and clinically relevant risk factor for stroke patients' outcome. Future studies should investigate how best to measure and define BPV in acute stroke. Larger studies are warranted to provide more robust evidence in this area.
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Affiliation(s)
- Yajing Chen
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Yuxia Ma
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China.
- The First Clinical Medical College of Lanzhou University, Lanzhou, 730030, Gansu Province, China.
| | - Jiangxia Qin
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Xiaoqin Wei
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Yiyi Yang
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Yue Yuan
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Fanghong Yan
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Xiaoning Huo
- The Third People's Hospital of Lanzhou, No.130 Jianlan New Village, Lanzhou, Gansu Province, China
| | - Lin Han
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China.
- Department of Nursing, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, Gansu Province, China.
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14
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Li L, Wu B, Dong J, He S, Xu J, Tse G, Dai F, Liu H. Hemodynamic changes in progressive cerebral infarction: An observational study based on blood pressure monitoring. J Clin Hypertens (Greenwich) 2024; 26:122-133. [PMID: 38192040 PMCID: PMC10857478 DOI: 10.1111/jch.14759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 01/10/2024]
Abstract
Progressive cerebral infarction (PCI) is a common complication in patients with ischemic stroke that leads to poor prognosis. Blood pressure (BP) can indicate post-stroke hemodynamic changes which play a key role in the development of PCI. The authors aim to investigate the association between BP-derived hemodynamic parameters and PCI. Clinical data and BP recordings were collected from 80 patients with cerebral infarction, including 40 patients with PCI and 40 patients with non-progressive cerebral infarction (NPCI). Hemodynamic parameters were calculated from the BP recordings of the first 7 days after admission, including systolic and diastolic BP, mean arterial pressure, and pulse pressure (PP), with the mean values of each group calculated and compared between daytime and nighttime, and between different days. Hemodynamic parameters and circadian BP rhythm patterns were compared between PCI and NPCI groups using t-test or non-parametric equivalent for continuous variables, Chi-squared test or Fisher's exact test for categorical variables, Cox proportional hazards regression analysis and binary logistic regression analysis for potential risk factors. In PCI and NPCI groups, significant decrease of daytime systolic BP appeared on the second and sixth days, respectively. Systolic BP and fibrinogen at admission, daytime systolic BP of the first day, nighttime systolic BP of the third day, PP, and the ratio of abnormal BP circadian rhythms were all higher in the PCI group. PCI and NPCI groups were significantly different in BP circadian rhythm pattern. PCI is associated with higher systolic BP, PP and more abnormal circadian rhythms of BP.
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Affiliation(s)
- Ling Li
- Department of NeurologyZhoushan HospitalWenzhou Medical UniversityZhoushanChina
| | - Bin Wu
- Department of NeurologyPeople's Hospital of QuzhouQuzhouChina
| | - Jiaoxuan Dong
- Department of NeurologyZhoushan HospitalWenzhou Medical UniversityZhoushanChina
| | - Songbin He
- Department of NeurologyZhoushan HospitalWenzhou Medical UniversityZhoushanChina
| | - Jie Xu
- Department of NeurologyZhoushan HospitalWenzhou Medical UniversityZhoushanChina
| | - Gary Tse
- School of Nursing and Health StudiesHong Kong Metropolitan UniversityHong KongChina
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular DiseaseDepartment of CardiologyTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
- Kent and Medway Medical SchoolUniversity of Kent and Canterbury Christ Church UniversityCanterburyKentUK
| | - Fangyu Dai
- Department of NeurologyZhoushan HospitalWenzhou Medical UniversityZhoushanChina
| | - Haipeng Liu
- Research Centre for Intelligent HealthcareCoventry UniversityCoventryUK
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15
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Ding X, Zhou Y, Pan Y, Xu J, Yan H, Zhao X, Wang Y, Wang Y. Dipping Pattern and 1-year stroke functional outcome in ischemic stroke or transient ischemic attack. Clin Exp Hypertens 2023; 45:2139384. [DOI: 10.1080/10641963.2022.2139384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Xia Ding
- Department of Nephrology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilun Zhou
- Department of Nephrology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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16
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Valencia Morales DJ, Garbajs NZ, Tawfic SS, Jose T, Laporta ML, Schroeder DR, Weingarten TN, Sprung J. Intraoperative Blood Pressure Variability and Early Postoperative Stroke: A Case-Control Study. Am Surg 2023; 89:5191-5200. [PMID: 36426383 DOI: 10.1177/00031348221136578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND This study aims to assess the association of postoperative stroke with intraoperative hemodynamic variability and transfusion management. METHODS In this case-control study, adult patients (≥ 18 years) who had a stroke within 72 hours of a surgical procedure were matched to 2 control patients according to age, sex, and procedure type. Primary risk factors assessed were intraoperative fluid administration, blood product transfusion, vasopressor use, and measures of variability in systolic and diastolic blood pressure and heart rate: maximum, minimum, range, SD, and average real variability. The variables were analyzed with conditional logistic regression, which accounted for the 1:2 matched case-control study design. RESULTS Among 687 581 procedures, we identified 64 postoperative strokes (incidence, 9.3 [95% CI, 7.2-11.9] strokes per 100 000 procedures). These cases were matched with 128 controls. Stroke cases had higher Charlson cmorbidity index scores than did controls (P = .046). Blood pressure and heart rate variability measures were not associated with stroke. The risk of stroke was increased with red blood cell (RBC) transfusion (odds ratio [OR], 14.82; 95% CI, 3.40-64.66; P < .001), vasopressor use (OR, 3.91; 95% CI, 1.59-9.60; P = .003), and longer procedure duration (OR, 1.23/h; 95% CI, 1.01-1.51; P = .04). Multivariable analysis of procedure duration, RBC transfusion, and vasopressor use showed that only RBC transfusion was independently associated with an increased risk of stroke (OR, 10.10; 95% CI, 2.14-47.72; P = .004). CONCLUSIONS Blood pressure variability was not associated with an increased risk of postoperative stroke; however, RBC transfusion was an independent risk factor.
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Affiliation(s)
| | - Nika Zorko Garbajs
- Department of Vascular Neurology and Intensive Therapy, University Medical Centre, Ljubljana, Slovenia
| | - Sarah S Tawfic
- Department of Internal Medicine, Mayo Clinic Rochester, Minnesota
| | - Thulasee Jose
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darrell R Schroeder
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Zang J, Tang X, Su X, Zhang T, Lu D, Xu A. Systematic Analysis of RNA Expression Profiles in Different Ischemic Cortices in MCAO Mice. Cell Mol Neurobiol 2023; 43:859-878. [PMID: 35449428 PMCID: PMC11415153 DOI: 10.1007/s10571-022-01220-9] [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: 12/24/2021] [Accepted: 03/29/2022] [Indexed: 11/03/2022]
Abstract
The prognosis of ischemic stroke patients is highly associated with the collateral circulation. And the competing endogenous RNAs (ceRNAs) generated from different compensatory supply regions may also involve in the regulation of ischemic tissues prognosis. In this study, we found the apoptosis progress of ischemic neurons in posterior circulation-supplied regions (close to PCA, cortex2) was much slower than that in anterior circulation-supplied territory (close to ACA, cortex1) in MCAO-3-h mice. Using the RNA sequencing and functional enrichment analysis, we analyzed the difference between RNA expression profile in cortex1 and cortex2 and the related biological processes. The results indicated that the differential expressed ceRNAs in cortex1 were involved in cell process under acute injury, while the differential expressed ceRNAs in cortex2 was more likely to participate in long-term injury and repair process. Besides, by establishing the miRNA-ceRNA interaction network we further sorted out two specifically distributed miRNAs, namely mmu-miR446i-3p (in cortex1) and mmu-miR3473d (in cortex2). And the specifically increased mmu-miR3473d in cortex2 mainly involved the angiogenesis and cell proliferation after ischemic stroke, which may be the critical reason for the longer therapeutic time window in cortex2. In conclusion, the present study reported the specific changes of ceRNAs in distinct compensatory regions potentially involved in the evolution of cerebral ischemic tissues and the unbalance prognosis after stroke. It provided more evidence for the collateral compensatory effects on patients' prognosis and carried out the new targets for the ischemic stroke therapy.
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Affiliation(s)
- Jiankun Zang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Jinan University, 613 West Huangpu Ave, Guangzhou, 510632, China
- Clinical Neuroscience Institute, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xionglin Tang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Jinan University, 613 West Huangpu Ave, Guangzhou, 510632, China
- Clinical Neuroscience Institute, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xuanlin Su
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Jinan University, 613 West Huangpu Ave, Guangzhou, 510632, China
- Clinical Neuroscience Institute, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Tianyuan Zhang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Jinan University, 613 West Huangpu Ave, Guangzhou, 510632, China
- Clinical Neuroscience Institute, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Dan Lu
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Jinan University, 613 West Huangpu Ave, Guangzhou, 510632, China.
- Clinical Neuroscience Institute, The First Affiliated Hospital of Jinan University, Guangzhou, China.
| | - Anding Xu
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Jinan University, 613 West Huangpu Ave, Guangzhou, 510632, China.
- Clinical Neuroscience Institute, The First Affiliated Hospital of Jinan University, Guangzhou, China.
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Periprocedure Management of Blood Pressure After Acute Ischemic Stroke. J Neurosurg Anesthesiol 2023; 35:4-9. [PMID: 36441847 DOI: 10.1097/ana.0000000000000891] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/30/2022]
Abstract
The management of acute ischemic stroke primarily revolves around the timely restoration of blood flow (recanalization/reperfusion) in the occluded vessel and maintenance of cerebral perfusion through collaterals before reperfusion. Mechanical thrombectomy is the most effective treatment for acute ischemic stroke due to large vessel occlusions in appropriately selected patients. Judicious management of blood pressure before, during, and after mechanical thrombectomy is critical to ensure good outcomes by preventing progression of cerebral ischemia as well hemorrhagic conversion, in addition to optimizing systemic perfusion. While direct evidence to support specific hemodynamic targets around mechanical thrombectomy is limited, there is increasing interest in this area. Newer approaches to blood pressure management utilizing individualized cerebral autoregulation-based targets are being explored. Early efforts at utilizing machine learning to predict blood pressure treatment thresholds and therapies also seem promising; this focused review aims to provide an update on recent evidence around periprocedural blood pressure management after acute ischemic stroke, highlighting its implications for clinical practice while identifying gaps in current literature.
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Liu T, Li Y, Niu X, Wang Y, Zhang K, Fan H, Ren J, Li J, Fang Y, Li X, Wu X. Factors affecting physician decision-making regarding antiplatelet therapy in minor ischemic stroke. Front Neurol 2022; 13:937417. [PMID: 36119700 PMCID: PMC9477012 DOI: 10.3389/fneur.2022.937417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose To identify the most important factors affecting physician decision-making regarding antiplatelet therapy. Methods We retrospectively gathered data from minor ischemic stroke patients with NIHSS scores ≤ 5 within 72 h of onset from 2010 to 2018. The population was divided into four groups by initial antiplatelet therapy: aspirin monotherapy (AM), dual antiplatelet therapy with aspirin and a loading dose of clopidogrel (clopidogrel loading dose of 300 mg on the first day; DAPT-ALC), dual antiplatelet therapy with aspirin and no loading dose of clopidogrel (clopidogrel 75 mg daily, no loading dose; DAPT-AUC), and clopidogrel monotherapy (CM). Results In total, 1,377 patients were included in the analysis (excluding patients who accepted thrombolytic drugs, participated in other clinical trials, or had not used antiplatelet drugs). The mean ± S.D. age was 62.0 ± 12.7 years; 973 (70.7%) patients were male. The four groups were AM (n = 541, 39.3%), DAPT-ALC (n = 474, 34.4%), DAPT- AUC (n = 301, 21.9%), and CM (n = 61, 4.4%). Patients receiving antiplatelet monotherapy were older than those receiving dual antiplatelet therapy (63.7–65.7 vs. 59.6–61.4 years), and the median initial systolic blood pressure level was higher in the DAPT-ALC group than in the other groups (all P < 0.05). Patients under 75 years old with an admission SBP lower than 180 mmHg, a history of AM, coronary heart disease, no history of intracerebral hemorrhage, stroke onset occurring after guideline recommendations were updated (the year of 2015), onset-to-arrival time within 24 h, and initial NIHSS score ≤ 3 were more likely to take DAPT-ALC than AM. Compared with DAPT-ALC, DAPT-AUC was associated with an initial SBP level lower than 180 mmHg, a history of smoking, hypertension, no history of ICH, previous treatment with antihypertensives, and onset year after the recommendations were updated. Conclusions Many factors affect doctors' decisions regarding antiplatelet therapy, especially guidelines, age, admission SBP level, and hypertensive disease.
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Affiliation(s)
- Tingting Liu
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Medical University, Taiyuan, China
| | - Yanan Li
- Shanxi Medical University, Taiyuan, China
| | - Xiaoyuan Niu
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, China
- *Correspondence: Xiaoyuan Niu
| | | | - Kaili Zhang
- The Bethune Hospital of Shanxi Province, Taiyuan, China
| | - Haimei Fan
- General Hospital of Tisco (Sixth Hospital of Shanxi Medical University), Shanxi, China
| | - Jing Ren
- Shanxi Medical University, Taiyuan, China
| | - Juan Li
- Shanxi Medical University, Taiyuan, China
| | - Yalan Fang
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xinyi Li
- The Bethune Hospital of Shanxi Province, Taiyuan, China
| | - Xuemei Wu
- General Hospital of Tisco (Sixth Hospital of Shanxi Medical University), Shanxi, China
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20
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Garbajs NZ, Singh TD, Valencia Morales DJ, Herasevich V, Warner DO, Martin DP, Knopman DS, Petersen RC, Hanson AC, Jennissen AJ, Schroeder DR, Weingarten TN, Gajic O, Rabinstein AA, Sprung J. Association of blood pressure variability with short- and long-term cognitive outcomes in patients with critical illness. J Crit Care 2022; 71:154107. [PMID: 35803011 DOI: 10.1016/j.jcrc.2022.154107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/20/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blood pressure variability (BPV), a modifiable risk factor, can compromise cerebral perfusion in critically ill patients. We studied the association between BPV in the intensive care unit (ICU) and short- and long-term cognitive outcomes. METHODS All patients were ≥50 years old. The short-term cognitive end points were delirium and depressed alertness without delirium. The long-term outcome was change in the slope of longitudinal cognitive scores. Primary BPV measure was average real variability (ARV) of systolic blood pressure. Associations were assessed with multivariable multinominal logistic regression and linear mixed effects models. RESULTS Of 794 patients (1130 admissions) 185 developed delirium and 274 developed depressed alertness. There was a dose-response association of 24-h systolic ARV with delirium (adjusted OR, 95% CI 2.15 per 5 mm Hg increase, 1.31-3.06, P < 0.017) and with depressed alertness (OR 1.89, 95% CI 1.18-3.03, P < 0.008). For 371 patients with available longitudinal cognitive scores, the decline in cognitive trajectory was accelerated after discharge (annual change OR -0.097, 95% CI -0.122 to -0.073). This acceleration increased with delirium (additional decline -0.132 [-0.233 to 0.030], P = 0.011). We found no significant association between BPV and post-ICU cognitive trajectory. CONCLUSIONS BPV was associated with increased likelihood of delirium in the ICU. Delirium, but not BPV, was associated with long-term cognitive decline.
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Affiliation(s)
- Nika Zorko Garbajs
- Department of Medicine, Division of Critical Care and Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA; Department of Vascular Neurology and Intensive Therapy, University Medical Centre Ljubljana, 1000, Slovenia
| | - Tarun D Singh
- Department of Medicine, Division of Critical Care and Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Vitaly Herasevich
- Department of Medicine, Division of Critical Care and Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David S Knopman
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Andrew C Hanson
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN 55905, USA
| | - Andrew J Jennissen
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN 55905, USA
| | - Darrell R Schroeder
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN 55905, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Ognjen Gajic
- Department of Medicine, Division of Critical Care and Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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21
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Hawkes MA, Anderson C, Rabinstein AA. Blood Pressure Variability After Cerebrovascular Events—A Possible New Therapeutic Target: A Narrative Review. Neurology 2022; 99:150-160. [DOI: 10.1212/wnl.0000000000200856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/29/2022] [Indexed: 11/15/2022] Open
Abstract
Blood pressure variability, the variation of blood pressure during a certain period, results from the interaction of hemodynamic, neuronal, humoral, behavioral, and environmental factors. Cerebral autoregulation is impaired in acute cerebrovascular disease. In these patients, increased blood pressure variability may provoke or exacerbate secondary brain injury. In fact, available data showed that increased Blood pressure variability is associated with worse outcomes after acute ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage. Consequently, blood pressure variability may represent a usual modifiable therapeutic target. This concept this particularly attractive because reduction of blood pressure variability can be feasible in regions with lower resources and can be applicable to patients with various forms of acute stroke. Prospective studies are needed to further clarify the relationship between blood pressure variability and secondary brain damage, and the determinants of blood pressure variability in different clinical populations. Ultimately, cerebrovascular disease-specific randomized controlled trials aimed at reducing blood pressure variability, irrespective of the absolute blood pressure values, are needed to determine if reduction of blood pressure variability can improve outcomes in patients with acute cerebrovascular disease.
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22
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Blood Pressure Variability Indices for Outcome Prediction After Thrombectomy in Stroke by Using High-Resolution Data. Neurocrit Care 2022; 37:220-229. [PMID: 35606560 PMCID: PMC9343264 DOI: 10.1007/s12028-022-01519-x] [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: 11/30/2021] [Accepted: 04/11/2022] [Indexed: 11/25/2022]
Abstract
Background Blood pressure variability (BPV) is associated with outcome after endovascular thrombectomy in acute large vessel occlusion stroke. We aimed to provide the optimal sampling frequency and BPV index for outcome prediction by using high-resolution blood pressure (BP) data. Methods Patient characteristics, 3-month outcome, and BP values measured intraarterially at 1 Hz for up to 24 h were extracted from 34 patients treated at a tertiary care center neurocritical care unit. Outcome was dichotomized (modified Rankin Scale 0–2, favorable, and 3–6, unfavorable) and associated with systolic BPV (as calculated by using standard deviation, coefficient of variation, averaged real variability, successive variation, number of trend changes, and a spectral approach using the power of specific BP frequencies). BP values were downsampled by either averaging or omitting all BP values within each prespecified time bin to compare the different sampling rates. Results Out of 34 patients (age 72 ± 12.7 years, 67.6% men), 10 (29.4%) achieved a favorable functional outcome and 24 (70.6%) had an unfavorable functional outcome at 3 months. No group differences were found in mean absolute systolic BP (SBP) (130 ± 18 mm Hg, p = 0.82) and diastolic BP (DBP) (59 ± 10 mm Hg, p = 1.00) during the monitoring time. BPV only reached predictive significance when using successive variation extracted from downsampled (averaged over 5 min) SBP data (median 4.8 mm Hg [range 3.8–7.1]) in patients with favorable versus 7.1 mmHg [range 5.5–9.7] in those with unfavorable outcome, area under the curve = 0.74 [confidence interval (CI) 0.57–0.85; p = 0.031], or the power of midrange frequencies between 1/20 and 1/5 min [area under the curve = 0.75 (CI 0.59–0.86), p = 0.020]. Conclusions Using high-resolution BP data of 1 Hz, downsampling by averaging all BP values within 5-min intervals is essential to find relevant differences in systolic BPV, as noise can be avoided (confirmed by the significance of the power of midrange frequencies). These results demonstrate how high-resolution BP data can be processed for effective outcome prediction. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01519-x.
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23
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Zhu J, Hao X, Tang H, Xu J, Wang A, Zhang X, Wang Y. Time point of nocturnal trough systolic blood pressure as an independent predictor of cardiovascular events. J Clin Hypertens (Greenwich) 2022; 24:283-291. [PMID: 35118806 PMCID: PMC8924997 DOI: 10.1111/jch.14404] [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: 07/05/2021] [Revised: 11/02/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Abstract
Nocturnal trough systolic blood pressure (NTSBP) and Time Point of Nocturnal Trough Systolic Blood Pressure (T‐NTSBP) were important parameters of nocturnal blood pressure, the predictive values of which are unclear for stroke outcome. This study aimed to examine the relationship between NTSBP/T‐NTSBP and stroke outcome. The authors used data from a nationwide ambulatory blood pressure monitoring cohort study conducted in China, which recruited 2348 ischemic stroke and transient ischemic attack (TIA) patients. NTSBP was defined as the lowest SBP during nighttime (22:00–6:00), and T‐NTSBP was defined as the corresponding time point of NTSBP. The associations between NTSBP/T‐NTSBP and stroke outcome (stroke recurrence and combined vascular event [CVE]) at 90 days or 1 year were analyzed using cox regression models. According to NTSBP classified by quartile, hazard ratio (HR) with 95% confidence interval (CI) for NTSBP quartile 4 (>129 mm Hg) was 2.727 (1.148–6.478) for CVE at 90‐day, compared with quartile 1 (≤102 mm Hg). However, an attenuated association between NTSBP and CVE was observed at 1 year. In addition, we observed the group of T‐NTSBP at 4:00–6:00 had a lowest CVE incidence at 90 days among four groups (22:00–23:59, 00:00–1:59 2:00–3:59, 4:00–6:00). After multivariable adjustment, T‐NTSBP was significantly associated with CVE incidence at 90 days (T‐NTSBP at the 4:00–6:00 versus the 22:00–23:59 group: HR, 0.433; 95%CI, 0.190–0.986), independent of NTSBP and average nocturnal SBP. Both of NTSBP and T‐NTSBP were important predictors for short‐term cardiovascular risk in ischemic stroke and TIA patients.
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Affiliation(s)
- Jing Zhu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Departments of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiwa Hao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Baotou Central Hospital, Inner Mongolia, China
| | - Hefei Tang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaoli Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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24
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Ge XB, Yang QF, Liu ZB, Zhang T, Liang C. Increased blood pressure variability predicts poor outcomes from endovascular treatment for aneurysmal subarachnoid hemorrhage. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:759-765. [PMID: 34669812 DOI: 10.1590/0004-282x-anp-2020-0167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 12/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Predictors of outcomes following endovascular treatment (ET) for aneurysmal subarachnoid hemorrhage (aSAH) are not well-defined. Identifying them would be beneficial in determining which patients might benefit from ET. OBJECTIVE To identify the predictive factors for poor outcomes following ET for aSAH. METHODS 120 patients with ruptured cerebral aneurysms underwent endovascular embolization between January 2017 and December 2018. Blood pressure variability was examined using the standard deviation of the 24-hour systolic blood pressure (24hSSD) and 24-hour diastolic blood pressure (24hDSD). Predictors were identified through univariate and multivariate regression analysis. All patients were followed up for three months. RESULTS At follow-up, 86 patients (71.7%) had good outcomes and 34 (28.3%) had poor outcomes. Patients with poor outcomes had significantly higher 24hSSD than those with good outcomes (19.3 ± 5.5 vs 14.1 ± 4.8 mmHg; P < 0.001). The 24hDSD did not differ significantly between patients with good outcomes and those with poor outcomes (9.5 ± 2.3 vs 9.9 ± 3.5 mmHg; P = 0.464). The following were significant risk factors for poor outcomes after endovascular embolization: age ≥ 65 years (odds ratio [OR] = 23.0; 95% confidence interval [CI]: 3.0-175.9; P = 0.002); Hunt-Hess grade 3-4 (OR = 6.8; 95% CI: 1.1-33.7; P = 0.039); Fisher grade 3-4 (OR = 47.1; 95% CI: 3.8-586.5; P = 0.003); postoperative complications (OR = 6.1; 95% CI: 1.1-34.8; P = 0.042); and 24hSSD ≥ 15 mmHg (OR = 14.9; 95% CI: 4.0-55.2; P < 0.001). CONCLUSION Elevated 24hSSD is a possibly treatable predictive factor for poor outcomes after ET for aSAH.
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Affiliation(s)
- Xin-Bo Ge
- Xingtai People's Hospital, Department of Neurosurgery, Xingtai, Hebei 054001, China
| | - Qun-Fu Yang
- Xingtai People's Hospital, Department of Neurosurgery, Xingtai, Hebei 054001, China
| | - Zhen-Bo Liu
- Xingtai People's Hospital, Department of Neurosurgery, Xingtai, Hebei 054001, China
| | - Tao Zhang
- Xingtai People's Hospital, Department of Neurosurgery, Xingtai, Hebei 054001, China
| | - Chao Liang
- Xingtai People's Hospital, Department of Neurosurgery, Xingtai, Hebei 054001, China
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25
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Peng TJ, Ortega-Gutiérrez S, de Havenon A, Petersen NH. Blood Pressure Management After Endovascular Thrombectomy. Front Neurol 2021; 12:723461. [PMID: 34539562 PMCID: PMC8446280 DOI: 10.3389/fneur.2021.723461] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
Endovascular thrombectomy (EVT) has changed the landscape of acute stroke therapy and has become the standard of care for selected patients presenting with anterior circulation large-vessel occlusion (LVO) stroke. Despite successful reperfusion, many patients with LVO stroke do not regain functional independence. Particularly, patients presenting with extremes of blood pressure (BP) or hemodynamic variability are found to have a worse clinical recovery, suggesting blood pressure optimization as a potential neuroprotective strategy. Current guidelines acknowledge the lack of randomized trials to evaluate the optimal hemodynamic management during the immediate post-stroke period. Following reperfusion, lower blood pressure targets may be warranted to prevent reperfusion injury and promote penumbral recovery, but adequate BP targets adjusted to individual patient factors such as degree of reperfusion, infarct size, and overall hemodynamic status remain undefined. This narrative review outlines the physiological mechanisms of BP control after EVT and summarizes key observational studies and clinical trials evaluating post-EVT BP targets. It also discusses novel treatment strategies and areas of future research that could aid in the determination of the optimal post-EVT blood pressure.
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Affiliation(s)
- Teng J Peng
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Santiago Ortega-Gutiérrez
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Adam de Havenon
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
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26
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Kim BJ, Singh N, Menon BK. Hemodynamics of Leptomeningeal Collaterals after Large Vessel Occlusion and Blood Pressure Management with Endovascular Treatment. J Stroke 2021; 23:343-357. [PMID: 34649379 PMCID: PMC8521259 DOI: 10.5853/jos.2021.02446] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 12/14/2022] Open
Abstract
Endovascular therapy (EVT) is an effective treatment for ischemic stroke due to large vessel occlusion (LVO). Unlike intravenous thrombolysis, EVT enables visualization of the restoration of blood flow, also known as successful reperfusion in real time. However, until successful reperfusion is achieved, the survival of the ischemic brain is mainly dependent on blood flow from the leptomeningeal collaterals (LMC). It plays a critical role in maintaining tissue perfusion after LVO via pre-existing channels between the arborizing pial small arteries or arterioles overlying the cerebral hemispheres. In the ischemic territory where the physiologic cerebral autoregulation is impaired and the pial arteries are maximally dilated within their capacity, the direction and amount of LMC perfusion rely on the systemic perfusion, which can be estimated by measuring blood pressure (BP). After the EVT procedure, treatment focuses on mitigating the risk of hemorrhagic transformation, potentially via BP reduction. Thus, BP management may be a key component of acute care for patients with LVO stroke. However, the guidelines on BP management during and after EVT are limited, mostly due to the scarcity of high-level evidence on this issue. In this review, we aim to summarize the anatomical and physiological characteristics of LMC to maintain cerebral perfusion after acute LVO, along with a landscape summary of the literature on BP management in endovascular treatment. The objective of this review is to describe the mechanistic association between systemic BP and collateral perfusion after LVO and thus provide clinical and research perspectives on this topic.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Nishita Singh
- Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Bijoy K. Menon
- Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
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27
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Abstract
This article aims to provide a comprehensive overview of key advances on various aspects of hyper-acute management of acute ischaemic stroke. These include neuroimaging, acute stroke unit care, management of blood pressure, reperfusion therapy including intravenous thrombolysis, mechanical thrombectomy and decompressive hemicraniectomy for malignant stroke syndrome. The challenge ahead is to ensure these evidence-based treatments are now being delivered and implemented to maximise the benefits across the population.
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Affiliation(s)
| | | | - Jonathan Birns
- St Thomas' Hospital, London, UK and deputy head of School of Medicine, Health Education England, London, UK
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28
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Liu D, Nie X, Pan Y, Yan H, Pu Y, Wei Y, Cai Y, Ding Y, Lu Q, Zhang Z, Gu W, Hou X, Yang Z, Wen M, Wang P, Ma G, Ma N, Miao Z, Leng X, Yan B, Davis SM, Wang Y, Liu L. Adverse Outcomes Associated With Higher Mean Blood Pressure and Greater Blood Pressure Variability Immediately After Successful Embolectomy in Those With Acute Ischemic Stroke, and the Influence of Pretreatment Collateral Circulation Status. J Am Heart Assoc 2021; 10:e019350. [PMID: 33634704 PMCID: PMC8174261 DOI: 10.1161/jaha.120.019350] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background To investigate whether collateral status could modify the associations between post‐thrombectomy blood pressure (BP) measures and outcomes. Methods and Results Patients with anterior‐circulation large‐vessel‐occlusion successfully recanalized in a multicenter endovascular thrombectomy registry were enrolled. Pretreatment collateral status was graded and dichotomized (good/poor) in angiography. Maximum, minimum, and mean systolic BP (SBP) and BP variability (assessed by the SD, coefficient of variation) during the initial 24 hours after endovascular thrombectomy were obtained. The primary outcome was unfavorable 90‐day outcome (modified Rankin Scale score 3–6). Secondary outcomes included symptomatic intracranial hemorrhage and 90‐day mortality. Adjusted odds ratios (aOR) of BP parameters over the outcomes were obtained in all patients and in patients with good/poor collaterals. Among 596 patients (mean age 66 years; 59.9% males), 302 (50.7%) patients had unfavorable 90‐day outcome. In multivariable analyses, higher mean SBP (aOR, 1.59 per 10 mm Hg increment; 95% CI, 1.26–2.02; P<0.001), mean SBP >140 mm Hg (versus ≤120 mm Hg; aOR, 4.27; 95% CI, 1.66–10.97; P=0.002), and higher SBP SD (aOR, 1.08 per 1‐SD increment; 95% CI, 1.01–1.16; P=0.02) were respectively associated with unfavorable 90‐day outcome in patients with poor collateral but not in those with good collateral. A marginal interaction between SBP coefficient of variation tertiles and collaterals on 90‐day functional outcome (P for interaction, 0.09) was observed. A significant interaction between SBP coefficient of variation tertiles and collaterals on 90‐day mortality (P for interaction, 0.03) was observed. Conclusions Higher postprocedural BP is associated with 90‐day unfavorable outcomes after successful endovascular thrombectomy in patients with poor collateral. Registration URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1900022154.
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Affiliation(s)
- Dacheng Liu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Ximing Nie
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuesong Pan
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Hongyi Yan
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuehua Pu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yufei Wei
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuan Cai
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yarong Ding
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Qixuan Lu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Zhe Zhang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Weibin Gu
- Department of Radiology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Xinyi Hou
- Department of Radiology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Zhonghua Yang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Miao Wen
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Penglian Wang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Gaoting Ma
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Ning Ma
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Zhongrong Miao
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Prince of Wales Hospital Chinese University of Hong Kong Hong Kong SAR China
| | - Bernard Yan
- Department of Medicine and Neurology Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of Melbourne Parkville Victoria Australia
| | - Stephen M Davis
- Department of Medicine and Neurology Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of Melbourne Parkville Victoria Australia
| | - Yongjun Wang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Liping Liu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
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29
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de Havenon A, Petersen N, Sultan-Qurraie A, Alexander M, Yaghi S, Park M, Grandhi R, Mistry E. Blood Pressure Management Before, During, and After Endovascular Thrombectomy for Acute Ischemic Stroke. Semin Neurol 2021; 41:46-53. [PMID: 33472269 PMCID: PMC8063274 DOI: 10.1055/s-0040-1722721] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There is an absence of specific evidence or guideline recommendations on blood pressure management for large vessel occlusion stroke patients. Until randomized data are available, the periprocedural blood pressure management of patients undergoing endovascular thrombectomy can be viewed in two phases relative to the achievement of recanalization. In the hyperacute phase, prior to recanalization, hypotension should be avoided to maintain adequate penumbral perfusion. The American Heart Association guidelines should be followed for the upper end of prethrombectomy blood pressure: ≤185/110 mm Hg, unless post-tissue plasminogen activator administration when the goal is <180/105 mm Hg. After successful recanalization (thrombolysis in cerebral infarction [TICI]: 2b-3), we recommend a target of a maximum systolic blood pressure of < 160 mm Hg, while the persistently occluded patients (TICI < 2b) may require more permissive goals up to <180/105 mm Hg. Future research should focus on generating randomized data on optimal blood pressure management both before and after endovascular thrombectomy, to optimize patient outcomes for these divergent clinical scenarios.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, Utah
| | - Nils Petersen
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Ali Sultan-Qurraie
- Department of Neurology, University of Washington, Valley Medical Center, Seattle, Washington
| | | | - Shadi Yaghi
- Department of Neurology, New York University, New York, New York
| | - Min Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Eva Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
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Svedung Wettervik T, Howells T, Lewén A, Enblad P. Blood Pressure Variability and Optimal Cerebral Perfusion Pressure-New Therapeutic Targets in Traumatic Brain Injury. Neurosurgery 2020; 86:E300-E309. [PMID: 31807783 DOI: 10.1093/neuros/nyz515] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/14/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Optimal cerebral perfusion pressure (CPPopt) is an autoregulatory-oriented target in the neurointensive care (NIC) of patients with traumatic brain injury (TBI), and deviation from CPPopt is associated with poor outcome. We recently found that blood pressure variability (BPV) is associated with deviation from CPPopt. OBJECTIVE To evaluate BPV and other variables related to deviation from CPPopt and to evaluate challenges and strategies for autoregulatory-oriented treatment in TBI. METHODS Data including arterial blood pressure and intracranial pressure (ICP) from 362 TBI patients treated at the NIC unit, Uppsala University Hospital, Sweden, between 2008 and 2016, were retrospectively analyzed day 2 to 5. RESULTS Higher BPV was a strong predictor of both CPP deviation below and above CPPopt after multiple regression analyses. There was no other explanatory variable for CPP deviation above CPPopt, whereas also higher ICP and worse autoregulation (higher pressure reactivity index) were associated with CPP deviation below CPPopt. A higher BPV was, in turn, explained by older age, lower ICP, higher mean arterial blood pressure, and higher slow arterial blood pressure amplitude (0.018-0.067 Hz). CONCLUSION BPV was strongly associated with deviation from CPPopt. High age is a risk factor for high BPV and hence CPP insults. Our treatment protocol is focused on avoiding CPP below 60 mm Hg. It is possible that a more restrictive upper level could generate more stable blood pressure and less deviation from CPPopt.
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Affiliation(s)
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Short-term outcome after ischemic stroke and 24-h blood pressure variability: association and predictors. Hypertens Res 2020; 44:188-196. [PMID: 32801313 DOI: 10.1038/s41440-020-00534-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/30/2020] [Accepted: 07/08/2020] [Indexed: 11/09/2022]
Abstract
To examine the association between blood pressure (BP) variability measured within 24 h after admission for acute ischemic stroke and functional outcome 30 days after stroke onset and to find outcome predictors. A total of 174 patients were included in this retrospective study. Supine BP was measured every 4 h during the first 24 h after admission. The functional outcome was assessed using the modified Rankin Scale. BP parameters including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and pulse pressure (PP) were examined. A set of six variability indices was calculated, including standard deviation (SD), successive variation (SV), difference between maximum and minimum value (DMM), and maximal successive change (MSC). Patients with high SBP or PP variability measures were significantly more likely to develop an unfavorable outcome. All PP variability indices displayed the highest correlations with the outcome. This association was confirmed in logistic regression analysis, both in univariable model and a model adjusted to the baseline National Institute of Health Stroke Scale score and mean BP (the OR for an unfavorable outcome following a 10-mmHg increase in SD, SV, MSC, and DMM parameters was in the interval 1.4-2.7, p < 0.05). Following receiver operating characteristic analysis, the PP parameters yielded area under the curve (AUC) values between 0.654 and 0.666, p < 0.005. Thus, in the acute phase of ischemic stroke, the SD and MSC indices of PP variability during the first 24 h after admission were robustly associated with patients' 30-day outcomes and served as predictors of unfavorable outcomes with thresholds of 14 and 26 mmHg, respectively.
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Nitroglycerin Is Not Associated with Improved Cerebral Perfusion in Acute Ischemic Stroke. Can J Neurol Sci 2020; 48:349-357. [PMID: 32799944 DOI: 10.1017/cjn.2020.179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The study was conducted to test the hypothesis that nitroglycerin (NTG) increases cerebral perfusion focally and globally in acute ischemic stroke patients, using serial perfusion-weighted imaging (PWI) magnetic resonance imaging measurements. PATIENTS AND METHODS Thirty-five patients underwent PWI immediately before and 72 h after administration of a transdermal NTG patch or no treatment. Patients with baseline mean arterial pressure (MAP) > 100 mmHg (NTG group, n = 20) were treated with transdermal NTG (0.2 mg/h) for 72 h, without a nitrate-free interval. Patients with MAP ≤ 100 mmHg (untreated group, n = 15) were not treated. The primary outcome measure was absolute cerebral blood flow (CBF) in the hypoperfused region at 72 h. RESULTS The mean baseline absolute CBF in the hypoperfused region was similar in the NTG group (33.3 ± 10.2 ml/100 g/min) and untreated (32.7 ± 8.4 ml/100 g/min, p = 0.4) groups. The median (IQR) baseline infarct volume was 10.4 (2.5-49.3) ml in the NTG group and 32.6 (8.6-96.7) ml in the untreated group (p = 0.09). MAP change in the NTG group was 1.2 ± 12.6 and 8 ± 20.7 mmHg at 2 h and 72 h, respectively. Mean absolute CBF in the hypoperfused region at 72 h was similar in the NTG (29.9 ± 12 ml/100 g/min) and untreated groups (24.1 ± 10 ml/100 g/min, p = 0.8). The median infarct volume increased in untreated (11.8 (5.7-44.2) ml) than the NTG group (3.2 (0.5-16.5) ml; p = 0.033) on univariate analysis, however, there was no difference on regression analysis. CONCLUSION NTG was not associated with improvement in cerebral perfusion in acute ischemic stroke patients.
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Katsanos AH, Alexandrov AV, Mandava P, Köhrmann M, Soinne L, Barreto AD, Sharma VK, Mikulik R, Muir KW, Rothlisberger T, Grotta JC, Levi CR, Molina CA, Saqqur M, Palaiodimou L, Psaltopoulou T, Vosko MR, Moreira T, Fiebach JB, Rubiera M, Sandset EC, Havenon A, Kent TA, Alexandrov AW, Schellinger PD, Tsivgoulis G. Pulse pressure variability is associated with unfavorable outcomes in acute ischaemic stroke patients treated with intravenous thrombolysis. Eur J Neurol 2020; 27:2453-2462. [DOI: 10.1111/ene.14447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/15/2020] [Indexed: 01/07/2023]
Affiliation(s)
- A. H. Katsanos
- Division of Neurology McMaster University/Population Health Research Institute Hamilton ON Canada
- Second Department of Neurology ‘Attikon’ University Hospital School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - A. V. Alexandrov
- Department of Neurology University of Tennessee Health Science Center Memphis TN USA
| | - P. Mandava
- Stroke Outcomes Laboratory Department of Neurology Baylor College of Medicine Houston TX USA
- Michael E. DeBakey VA Medical Center Stroke Program and Center for Translational Research on Inflammatory Diseases Houston TX USA
| | - M. Köhrmann
- Department of Neurology University Hospital Essen Essen Germany
| | - L. Soinne
- Department of Neurology Helsinki University Hospital and Clinical Neurosciences University of Helsinki Helsinki Finland
| | - A. D. Barreto
- Department of Neurology University of Texas Health Science Center at Houston Houston TX USA
| | - V. K. Sharma
- Department of Medicine Yong Loo Lin School of Medicine National University of Singapore and Division of Neurology National University Hospital Singapore Singapore
| | - R. Mikulik
- International Clinical Research Centre and Department of Neurology St Anne’s University Hospital in Brno and Medical FacultyMasaryk University Brno Czech Republic
| | - K. W. Muir
- Institute of Neuroscience and Psychology University of GlasgowQueen Elizabeth University Hospital Glasgow UK
| | | | - J. C. Grotta
- Clinical Innovation and Research Institute Memorial Hermann Hospital‐Texas Medical Center Houston TX USA
| | - C. R. Levi
- Department of Neurology John Hunter Hospital University of Newcastle Newcastle NSW Australia
| | - C. A. Molina
- Stroke Unit Department of Neurology Vall d'Hebron University Hospital Vall d'Hebron Research Institute Autonomous University of Barcelona Barcelona Spain
| | - M. Saqqur
- Department of Medicine (Neurology) University of Alberta Edmonton Alberta Canada
- Neuroscience Institute Hamad Medical Corporation Doha Qatar
| | - L. Palaiodimou
- Second Department of Neurology ‘Attikon’ University Hospital School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - T. Psaltopoulou
- Department of Hygiene, Epidemiology, and Medical Statistics School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - M. R. Vosko
- Department of Neurology 2 Med Campus III Kepler University Hospital Linz Austria
| | - T. Moreira
- Department of Neurology Karolinska University Hospital Stockholm Sweden
| | - J. B. Fiebach
- Center for Stroke Research Berlin Charité‐University Medicine Berlin Berlin Germany
| | - M. Rubiera
- Stroke Unit Department of Neurology Vall d'Hebron University Hospital Vall d'Hebron Research Institute Autonomous University of Barcelona Barcelona Spain
| | - E. C. Sandset
- Department of Neurology Stroke Unit Oslo University Hospital Oslo Norway
| | - A. Havenon
- Department of Neurology Clinical Neurosciences Center University of Utah Salt Lake City UT USA
| | - T. A. Kent
- Texas A&M Health Science Center‐Houston campusUniversity of Texas Houston TX USA
- Department of Neurology Houston Methodist Hospital Houston TX USA
| | - A. W. Alexandrov
- Department of Neurology University of Tennessee Health Science Center Memphis TN USA
| | - P. D. Schellinger
- Departments of Neurology and Neurogeriatry John Wesling Medical Center Minden Ruhr University Bochum Minden Germany
| | - G. Tsivgoulis
- Second Department of Neurology ‘Attikon’ University Hospital School of Medicine National and Kapodistrian University of Athens Athens Greece
- Department of Neurology University of Tennessee Health Science Center Memphis TN USA
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Nguyen T, Pope K, Capobianco P, Cao-Pham M, Hassan S, Kole MJ, O'Connell C, Wessell A, Strong J, Tran QK. Sedation Patterns and Hyperosmolar Therapy in Emergency Departments were Associated with Blood Pressure Variability and Outcomes in Patients with Spontaneous Intracranial Hemorrhage. J Emerg Trauma Shock 2020; 13:151-160. [PMID: 33013096 PMCID: PMC7472811 DOI: 10.4103/jets.jets_76_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/02/2019] [Accepted: 11/21/2019] [Indexed: 11/04/2022] Open
Abstract
Background Spontaneous intracranial hemorrhage (sICH) is associated with high mortality. Little information exists to guide initial resuscitation in the emergency department (ED) setting. However, blood pressure variability (BPV) and mechanical ventilation (MV) are known risk factors for poor outcome in sICH. Objectives The objective was to examine the associations between BPV and MV in ED (EDMV) and between two ED interventions - post-MV sedation and hyperosmolar therapy for elevated intracranial pressure - and BPV in the ED and in-hospital mortality. Methods We retrospectively studied adults with sICH and external ventricular drainage who were transferred to a quaternary academic medical center from other hospitals between January 2011 and September 2015. We used multivariable linear and logistic regressions to measure associations between clinical factors, BPV, and outcomes. Results We analyzed ED records from 259 patients. There were 143 (55%) EDMV patients who had more severe clinical factors and significantly higher values of all BPV indices than NoEDMV patients. Two clinical factors and none of the severity scores (i.e., Hunt and Hess, World Federation of Neurological Surgeons Grades, ICH score) correlated with BPV. Hyperosmolarity therapy without fluid resuscitation positively correlated with all BPV indices, whereas propofol infusion plus a narcotic negatively correlated with one of them. Two BPV indices, i.e., successive variation of blood pressure (BPSV) and absolute difference in blood pressure between ED triage and departure (BPDepart - Triage), were significantly associated with increased mortality rate. Conclusion Patients receiving MV had significantly higher BPV, perhaps related to disease severity. Good ED sedation, hyperosmolar therapy, and fluid resuscitation were associated with less BPV and lower likelihood of death.
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Affiliation(s)
- Tina Nguyen
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD, USA
| | - Kanisha Pope
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD, USA
| | - Paul Capobianco
- Research Associate Program in Emergency Medicine and Critical Care, University of Maryland, School of Medicine, College Park, MD, USA
| | - Mimi Cao-Pham
- Research Associate Program in Emergency Medicine and Critical Care, University of Maryland, School of Medicine, College Park, MD, USA
| | - Soha Hassan
- Department of Statistics, University of Maryland at College Park, College Park, MD, USA
| | - Matthew J Kole
- Department of Neurosurgery, University of Maryland School of Medicine, College Park, MD, USA
| | - Claire O'Connell
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD, USA
| | - Aaron Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, College Park, MD, USA
| | - Jonathan Strong
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD, USA
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD, USA.,R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, College Park, MD, USA
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Thatikonda N, Khandait V, Shrikhande A, Singh K. Role of 24-Hr Blood Pressure Variability as a Target Therapeutic Risk Factor for Poor Functional Outcome of Acute Ischemic Stroke. Ann Indian Acad Neurol 2020; 23:25-31. [PMID: 32055118 PMCID: PMC7001437 DOI: 10.4103/aian.aian_373_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/20/2019] [Accepted: 09/29/2019] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose: The present study aims to evaluate the role of blood pressure variability (BPV) as a target therapeutic risk factor for poor outcome of ischemic stroke by finding the association between the two and by finding the population attributable risk (PAR) of BPV compared to other baseline outcome predictors. Methods: A prospective observational study was carried out at GMCH, Nagpur, India from January to June 2019 in 75 patients diagnosed with acute ischemic stroke. BP was recorded hourly for the first 24 hours of admission and base line factors were collected along with measurement of stroke severity. BPV was measured by index of average real-time variability (ARV) while discharge outcome was measured by Barthel Index. Results: 36.5% of patients had poor outcome at discharge. A significant association was found between 24-hr ARV of systolic BP and poor outcome (P = 0.002, 95% CI = 2.22-23.5). Five factors were found to be independent outcome predictors on multiple logistic regression (OR, 95% CI): age (1.07, 1.03–1.10), NIHSS score (1.12, 1.04–1.27), on admission SBP (5.12, 4.01–16.23), on admission RBS (2.23, 1.92–6.49) and 24 Hr ARV-SBP (9.65, 3.02–20.1). The PAR of 24 hr ARV-SBP was 23.6%, second only to NIHSS score (26.4%). Conclusions: Reduction in BP variability might have a beneficial impact on the outcome of patients with acute ischemic stroke. There is further scope to explore optimum therapeutic strategies to minimize BPV in the management of acute ischemic stroke.
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Affiliation(s)
- Nithisha Thatikonda
- Undergraduate Medical Student, Govt. Medical College Nagpur, MUHS, Nagpur, Maharashtra, India
| | - Vinod Khandait
- Department of Medicine, Govt. Medical College Nagpur, MUHS, Nagpur, Maharashtra, India
| | - Aditya Shrikhande
- Undergraduate Medical Student, Govt. Medical College Nagpur, MUHS, Nagpur, Maharashtra, India
| | - Krittika Singh
- Undergraduate Medical Student, Govt. Medical College Nagpur, MUHS, Nagpur, Maharashtra, India
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Mistry EA, Mehta T, Mistry A, Arora N, Starosciak AK, De Los Rios La Rosa F, Siegler JE, Chitale R, Anadani M, Yaghi S, Khatri P, de Havenon A. Blood Pressure Variability and Neurologic Outcome After Endovascular Thrombectomy: A Secondary Analysis of the BEST Study. Stroke 2019; 51:511-518. [PMID: 31813361 DOI: 10.1161/strokeaha.119.027549] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose- Although higher blood pressure variability (BPV) is associated with worse functional outcome after stroke, this association is not as well established in large vessel occlusion strokes treated with endovascular treatment (EVT). Methods- In this post hoc analysis of BEST (Blood Pressure after Endovascular Therapy for Ischemic Stroke), a prospective, multicenter cohort study of anterior circulation acute ischemic stroke patients undergoing EVT, we determined the association of BPV with poor outcome or death (90-day modified Rankin Scale, 3-6). We calculated BPV during the first 24 hours after EVT for systolic and diastolic BP using 5 methodologies, then divided BPV into tertiles and compared the highest to lowest tertile using logistic regression. Results- Of the 443 patients included in our analysis, 259 (58.5%) had a poor outcome, and 79 (17.8%) died. All measures of BPV were significantly higher in patients with poor outcome or death, but the difference was more pronounced for systolic than diastolic BPV. In the logistic regression, the highest tertile of systolic BPV consistently predicted poor outcome (odds ratio, 1.8-3.5, all P<0.05). The rate of death within 90 days was 10.1% in the tertile with the lowest systolic BPV versus 25.2% in the tertile with the highest BPV (P<0.001). Conclusions- In EVT-treated stroke patients, higher BPV in the first 24 hours is associated with worse 90-day outcome. This association was more robust for systolic BPV. The mechanism by which BPV may exert a negative influence on neurological outcome remains unknown, but the consistency of this association warrants further investigation and potentially intervention.
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Affiliation(s)
- Eva A Mistry
- From the Department of Neurology, Vanderbilt University Medical Center, Nashville, TN (E.A.M.)
| | - Tapan Mehta
- Department of Neurology and Neurosurgery, University of Minnesota, Minneapolis (T.M.)
| | - Akshitkumar Mistry
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN (A.M., R.C.)
| | - Niraj Arora
- Department of Neurology, University of Missouri, Columbia (N.A.)
| | - Amy K Starosciak
- Baptist Health Neuroscience Center, Miami, FL (A.K.S., F.D.L.R.L.R.)
| | | | | | - Rohan Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN (A.M., R.C.)
| | - Mohammad Anadani
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO (M.A.)
| | - Shadi Yaghi
- Department of Neurology, New York University Langone Health, Brooklyn (S.Y.)
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K.)
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City (A.d.H.)
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de Havenon A, Fino NF, Johnson B, Wong KH, Majersik JJ, Tirschwell D, Rost N. Blood Pressure Variability and Cardiovascular Outcomes in Patients With Prior Stroke: A Secondary Analysis of PRoFESS. Stroke 2019; 50:3170-3176. [PMID: 31537194 PMCID: PMC6817411 DOI: 10.1161/strokeaha.119.026293] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/13/2019] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Every year in the United States, almost 185 000 ischemic strokes occur in patients with a prior stroke. Recurrent stroke has significantly higher morbidity and mortality. Among modifiable risk factors for recurrent stroke, hypertension is the most prevalent. Reducing systolic blood pressure is standard of care for secondary stroke prevention. Recent literature suggests that increased blood pressure variability (BPV) is associated with primary stroke, although studies have not convincingly shown that it is associated with recurrent stroke, which was the goal of this analysis. Methods- We conducted a secondary analysis of 17 916 patients in the PRoFESS (Prevention Regimen for Effectively Avoiding Second Strokes) trial, which is the largest trial of patients with potential recurrent stroke. We calculated BPV and evaluated its effect on recurrent stroke (composite and stratified by ischemic or hemorrhagic stroke), major cardiovascular events (death from cardiovascular causes, recurrent stroke, myocardial infarction, or new or worsening heart failure), and all-cause death. Results- Both systolic and diastolic BPV were associated with recurrent stroke, major cardiovascular events, and all-cause death. The association with stroke was significant for ischemic, but not hemorrhagic, stroke. For every 10-point increase in BPV (systolic SD, range =0-54.2), the hazard ratio for a recurrent ischemic stroke was 1.15 (95% CI, 1.02-1.32; P=0.02), for major cardiovascular events was 1.19 (95% CI, 1.09-1.31; P<0.001), and for all-cause death was 1.24 (95% CI, 1.10-1.39; P<0.001). Conclusions- Our study adds to the growing body of literature suggesting that BPV is an important and potentially modifiable risk factor for ischemic stroke, cardiovascular events, and all-cause death. Specifically, it is the first study to demonstrate that increased BPV is associated with recurrent ischemic stroke and that diastolic BPV can be as important as systolic BPV. Future work should focus on evaluating whether actively reducing BPV, using widely available and inexpensive antihypertensive medications, reduces the risk of cardiovascular disease.
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Affiliation(s)
- Adam de Havenon
- From the Department of Neurology (A.d.H., B.J., K.-H.W., J.J.M.), University of Utah, Salt Lake City
| | - Nora F Fino
- Division of Epidemiology, Department of Internal Medicine (N.F.F.), University of Utah, Salt Lake City
| | - Brian Johnson
- From the Department of Neurology (A.d.H., B.J., K.-H.W., J.J.M.), University of Utah, Salt Lake City
| | - Ka-Ho Wong
- From the Department of Neurology (A.d.H., B.J., K.-H.W., J.J.M.), University of Utah, Salt Lake City
| | - Jennifer J Majersik
- From the Department of Neurology (A.d.H., B.J., K.-H.W., J.J.M.), University of Utah, Salt Lake City
| | - David Tirschwell
- Department of Neurology, University of Washington, Seattle (D.T.)
| | - Natalia Rost
- Department of Neurology, Massachusetts General Hospital, Boston (N.R.)
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Nagel S, Joly O, Pfaff J, Papanagiotou P, Fassbender K, Reith W, Möhlenbruch MA, Herweh C, Grunwald IQ. e-ASPECTS derived acute ischemic volumes on non-contrast-enhanced computed tomography images. Int J Stroke 2019; 15:995-1001. [PMID: 31570065 PMCID: PMC7739116 DOI: 10.1177/1747493019879661] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and purpose Validation of automatically derived acute ischemic volumes (AAIV) from e-ASPECTS on non-contrast computed tomography (NCCT). Materials and methods Data from three studies were reanalyzed with e-ASPECTS Version 7. AAIV was calculated in milliliters (ml) in all scored ASPECTS regions of the hemisphere detected by e-ASPECTS. The National Institute of Health Stroke Scale (NIHSS) determined stroke severity at baseline and clinical outcome was measured with the modified Rankin Scale (mRS) between 45 and 120 days. Spearman ranked correlation coefficients (R) of AAIV and e-ASPECTS scores with NIHSS and mRS as well as Pearson correlation of AAIV with diffusion-weighted imaging and CT perfusion-estimated ischemic “core” volumes were calculated. Multivariate regression analysis (odds ratio, OR with 95% confidence intervals, CI) and Bland–Altman plots were performed. Results We included 388 patients. Mean AAIV was 11.6 ± 18.9 ml and e-ASPECTS was 9 (8–10: median and interquartile range). AAIV, respectively e-ASPECTS correlated with NIHSS at baseline (R = 0.35, p < 0.001; R = −0.36, p < 0.001) and follow-up mRS (R = 0.29, p < 0.001; R = −0.3, p < 0.001). In subsets of patients, AAIV correlated strongly with diffusion-weighted imaging (n = 37, R = 0.68, p < 0.001) and computed tomography perfusion-derived ischemic “core” (n = 41, R = 0.76, p < 0.001) lesion volume and Bland–Altman plots showed a bias close to zero (−2.65 ml for diffusion-weighted imaging and 0.45 ml forcomputed tomography perfusion “core”). Within the whole cohort, the AAIV (OR 0.98 per ml, 95% CI 0.96–0.99) and e-ASPECTS scores (OR 1.3, 95%CI 1.07–1.57) were independent predictors of good outcome Conclusion AAIV on NCCT correlated moderately with clinical severity but strongly with diffusion-weighted imaging lesion and computed tomography perfusion ischemic “core” volumes and predicted clinical outcome.
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Affiliation(s)
- Simon Nagel
- Department of Neurology, University Hospital Heidelberg, Germany
| | | | - Johannes Pfaff
- Department of Neuroradiology, University Hospital Heidelberg, Germany
| | | | - Klaus Fassbender
- Department of Neurology, University of the Saarland, Homburg, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, University of the Saarland, Homburg, Germany
| | | | - Christian Herweh
- Department of Neuroradiology, University Hospital Heidelberg, Germany
| | - Iris Q Grunwald
- Brainomix Ltd, Oxford, UK.,Neuroscience Department, Anglia Ruskin University, Essex, UK
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Zhang T, Wang X, Wen C, Zhou F, Gao S, Zhang X, Lin S, Shi J, Li W. Effect of short-term blood pressure variability on functional outcome after intra-arterial treatment in acute stroke patients with large-vessel occlusion. BMC Neurol 2019; 19:228. [PMID: 31558167 PMCID: PMC6764143 DOI: 10.1186/s12883-019-1457-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/04/2019] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Tianli Zhang
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Xiaolong Wang
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Chao Wen
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Feng Zhou
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Shengwei Gao
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Xiaodong Zhang
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Shiqin Lin
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Jing Shi
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Weirong Li
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China.
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de Havenon A, Stoddard G, Saini M, Wong KH, Tirschwell D, Bath P. Increased blood pressure variability after acute ischemic stroke increases the risk of death: A secondary analysis of the Virtual International Stroke Trial Archive. JRSM Cardiovasc Dis 2019; 8:2048004019856496. [PMID: 31217966 PMCID: PMC6560789 DOI: 10.1177/2048004019856496] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/08/2019] [Accepted: 05/10/2019] [Indexed: 11/16/2022] Open
Abstract
Background Despite promising epidemiological data, it remains unclear if increased blood
pressure variability is associated with death after acute ischemic stroke.
Our objective was to examine this association in a large cohort of acute
ischemic stroke patients. Methods We conducted a retrospective analysis of anonymized, pooled, participant data
from the Virtual International Stroke Trial Archive. We included patients
with a 90-day modified Rankin Scale and blood pressure readings in the 24 h
after study enrollment. The exposure was blood pressure variability during
the day after study enrollment, calculated for the systolic and diastolic
blood pressure using six statistical methodologies. The primary outcome was
death within 90 days of stroke onset. Results Our cohort comprised 1891 patients of whom 277 (14.7%) died within 90 days.
All indices of blood pressure variability were higher in patients who died,
but the difference was more pronounced for systolic than diastolic blood
pressure variability (systolic standard deviation for alive versus dead
patients = 13.4 versus 15.9 mmHg, p < 0.001). Similar results were found
in logistic regression models fit to the outcome of death, but only systolic
blood pressure variability remained significant in adjusted models (Odds
Ratio for death when comparing highest to lowest tercile of systolic blood
pressure variability = 1.41–1.89, p < 0.03 for all). Conclusions and relevance: These results reinforce prior studies
that found increased blood pressure variability is associated with worse
neurologic outcome after stroke. These data should help guide research on
blood pressure variability after stroke and advocate for the inclusion of
death as a clinical outcome in future studies that therapeutically reduce
blood pressure variability.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, USA
| | - Greg Stoddard
- Department of Preventative Medicine, University of Utah, Salt Lake City, USA
| | - Monica Saini
- Department of Neurology, Changi General Hospital, Singapore, Singapore
| | - Ka-Ho Wong
- Department of Neurology, University of Utah, Salt Lake City, USA
| | - David Tirschwell
- Department of Neurology, University of Washington, Washington, USA
| | - Phillip Bath
- Stroke Trials Unit, Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Chang JY, Jeon SB, Jung C, Gwak DS, Han MK. Postreperfusion Blood Pressure Variability After Endovascular Thrombectomy Affects Outcomes in Acute Ischemic Stroke Patients With Poor Collateral Circulation. Front Neurol 2019; 10:346. [PMID: 31031686 PMCID: PMC6473026 DOI: 10.3389/fneur.2019.00346] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 03/21/2019] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose: We evaluated the effect of 24 h blood pressure variability (BPV) on clinical outcomes in acute ischemic stroke patients with successful recanalization after endovascular recanalization therapy (ERT). Methods: Patients with anterior circulation occlusion were evaluated if they underwent ERT based on multiphase computed tomography angiography and achieved successful recanalization (≥thrombolysis in cerebral ischemia 2b). Collateral degrees were dichotomized based on the pial arterial filling score, with a score of 0-3 defined as a poor collateral status. BPV parameters include mean, standard deviation, coefficient of variation, and variation independent of the mean (VIM) for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure, and pulse rate (PR). These parameters were measured for 24 h after ERT and were analyzed according to occlusion sites and stroke mechanisms. Associations of BPV parameters with clinical outcomes were investigated with stratification based on the baseline collateral status. Results: BPV was significantly different according to the occlusion sites and stroke mechanisms, and higher BPV was observed in patients with internal carotid artery occlusion or cardioembolic occlusion. After adjustment for confounders, most BPV parameters remained significant to predict functional outcomes at 3 months in patients with poor collateral circulation. However, no significant association was found between BPV parameters and clinical outcomes in patients with good collateral circulation. Conclusion: Postreperfusion BP management by decreasing BPV may have influence on improving clinical outcome in cases of poor collateral circulation among patients achieving successful recanalization after ERT.
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Affiliation(s)
- Jun Young Chang
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dong Seok Gwak
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, College of Medicine, Seoul National University, Seoul, South Korea
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Blood pressure variability and outcome in acute ischemic and hemorrhagic stroke: a post hoc analysis of the HeadPoST study. J Hum Hypertens 2019; 33:411-418. [PMID: 30894658 PMCID: PMC6544517 DOI: 10.1038/s41371-019-0193-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/21/2019] [Accepted: 03/11/2019] [Indexed: 11/16/2022]
Abstract
The Head Positioning in Acute Stroke Trial (HeadPoST) is a pragmatic, international, cluster crossover randomized trial of 11,093 patients with acute stroke assigned to a lying-flat (0°) or sitting-up (head elevated ≥30°) position. This post-hoc analysis aimed to determine the association between BPV and outcomes for patients from a wide range of international clinical settings and how the association was modified by randomized head position. BPV was defined according to standard criteria with the key parameter considered the coefficient of variation (CV) of systolic BP (SBP) over 24 hours. Outcome was ordinal 90-day modified Rankin Scale (mRS) score. The association was analyzed by ordinal, logistic regression, hierarchical, mixed models with fixed intervention (lying-flat vs. sitting-up), and fixed period, random cluster, and random cluster-period, effects. 9,156 (8,324 AIS and 817 ICH; mean age 68.1 years; 39.2% women) were included in the analysis. CV of SBP had a significant linear association with unfavorable shift of mRS at 90 days (adjusted odds ratio [OR] 1.06, 95% confidence interval [CI] 1.02-1.11; P=0.01). There was no heterogeneity of the association by randomized head positioning. In addition, CV of diastolic BP (DBP) (1.08, 1.03-1.12; P=0.001) over 24 hours post stroke, was significantly associated with 3-month poor outcome. The association was more apparent in sitting-up position (1.12, 1.06-1.19) compared with lying-flat position (1.03, 0.98-1.09) (P interaction = 0.005). BPV was associated with adverse stroke outcome, the magnitude of the association was greater with sitting-up head positioning in terms of DBP variability.
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Lam MY, Haunton VJ, Robinson TG, Panerai RB. Dynamic cerebral autoregulation measurement using rapid changes in head positioning: experiences in acute ischemic stroke and healthy control populations. Am J Physiol Heart Circ Physiol 2019; 316:H673-H683. [DOI: 10.1152/ajpheart.00550.2018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The ideal technique for dynamic cerebral autoregulation (dCA) assessment in critically ill patients should provide considerable variability in blood pressure (BP) but without the need for patient cooperation. We proposed using rapid head positioning (RHP) over spontaneous BP fluctuations for dCA assessment in patients with acute ischemic stroke (AIS). Cerebral blood velocity (transcranial Doppler), beat-to-beat BP (Finometer), and end-tidal CO2 (capnography) were recorded during 5-min baseline and RHP in 16 controls (8 women and 8 men, mean age: 57 ± 16 yr) and 15 patients with AIS (7 women and 8 men, mean age: 69 ± 8 yr) at two (12 ± 8 days) and three visits (13.3 ± 6.9 h, 4.8 ± 3.2 days, and 93.9 ± 11.5 days from the symptom onset), respectively. All participants were able to complete the RHP protocol without difficulty. Compared with controls, patients with AIS were hypocapnic (all visits, P < 0.0024) and hypertensive ( visit 1, P = 0.011), although BP gradually reduced after the acute phase. RHP demonstrated greater beat-to-beat BP variability (BPV) in controls ( visits 1 and 2, P < 0.001) but not in patients with AIS at any visit. Compared with controls, a reduced autoregulation index (ARI) was demonstrated in patients with AIS, at visit 2 for the baseline recording but not at other visits or during RHP. The area under the receiver-operating curve was 0.53 and 0.54 for baseline and RHP, respectively. The RHP paradigm required minimal patient cooperation and could be considered a feasible alternative for assessing dCA, mainly in conditions leading to increased BPV. The lack of BPV increase in AIS with RHP deserves further investigation. NEW & NOTEWORTHY This study used rapid head positioning (RHP) to enhance blood pressure (BP) variability (BPV) to improve BP signal-to-noise ratio and reliability of dynamic cerebral autoregulation (dCA). RHP was well accepted by controls and acute ischemic stroke (AIS); the increased BPV induced in controls was not observed in AIS, suggesting BPV at rest was already elevated. RHP did not improve detection of impaired CA in AIS; further work is needed to understand the different responses observed.
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Affiliation(s)
- Man Y. Lam
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Victoria J. Haunton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institutes for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Thompson G. Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institutes for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Ronney B. Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institutes for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
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Vitt JR, Trillanes M, Hemphill JC. Management of Blood Pressure During and After Recanalization Therapy for Acute Ischemic Stroke. Front Neurol 2019; 10:138. [PMID: 30846967 PMCID: PMC6394277 DOI: 10.3389/fneur.2019.00138] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/04/2019] [Indexed: 12/31/2022] Open
Abstract
Ischemic stroke is a common neurologic condition and can lead to significant long term disability and death. Observational studies have demonstrated worse outcomes in patients presenting with the extremes of blood pressure as well as with hemodynamic variability. Despite these associations, optimal hemodynamic management in the immediate period of ischemic stroke remains an unresolved issue, particularly in the modern era of revascularization therapies. While guidelines exist for BP thresholds during and after thrombolytic therapy, there is substantially less data to guide management during mechanical thrombectomy. Ideal blood pressure targets after attempted recanalization depend both on the degree of reperfusion achieved as well as the extent of infarction present. Following complete reperfusion, lower blood pressure targets may be warranted to prevent reperfusion injury and promote penumbra recovery however prospective clinical trials addressing this issue are warranted.
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Affiliation(s)
- Jeffrey R. Vitt
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Michael Trillanes
- Department of Pharmaceutical Services, University of California, San Francisco, San Francisco, CA, United States
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
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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: 4.0] [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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Tuteja G, Uppal A, Strong J, Nguyen T, Pope K, Jenkins R, Al Rebh H, Gatz D, Chang WT, Tran QK. Interventions affecting blood pressure variability and outcomes after intubating patients with spontaneous intracranial hemorrhage. Am J Emerg Med 2018; 37:1665-1671. [PMID: 30528041 DOI: 10.1016/j.ajem.2018.11.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/23/2018] [Accepted: 11/28/2018] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Spontaneous intracranial hemorrhage (sICH) that increases intracranial pressure (ICP) is a life-threatening emergency often requiring intubation in Emergency Departments (ED). A previous study of intubated ED patients found that providing ≥5 interventions after initiating mechanical ventilation (pMVI) reduced mortality rate. We hypothesized that pMVIs would lower blood pressure variability (BPV) in patients with sICH and thus improve survival rates and neurologic outcomes. METHOD We performed a retrospective study of adults, who were transferred to a quaternary medical center between 01/01/2011 and 09/30/2015 for sICH, received an extraventricular drain during hospitalization. They were identified by International Classification of Diseases, version 9 (430.XX, 431.XX), and procedure code 02.21. Outcomes were BPV indices, death, and being discharged home. RESULTS We analyzed records from 147 intubated patients transferred from 40 EDs. Forty-one percent of patients received ≥5 pMVIs and was associated with lower median successive variation in systolic blood pressure (BPSV) (31,[IQR 18-45) compared with those receiving 4 or less pMVIs (38[IQR 16-70]], p = 0.040). Three pMVIs, appropriate tidal volume, sedative infusion, and capnography were significantly associated with lower BPV. In addition to clinical factors, BPSV (OR 26; 95% CI 1.2, >100) and chest radiography (OR 0.3; 95% CI 0.09, 0.9) were associated with mortality rate. Use of quantitative capnography (OR 8.3; 95%CI, 4.7, 8.8) was associated with increased likelihood of being discharged home. CONCLUSIONS In addition to disease severity, individual pMVIs were significantly associated with BPV and patient outcomes. Emergency physicians should perform pMVIs more frequently to prevent BPV and improve patients' outcomes.
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Affiliation(s)
- Gurshawn Tuteja
- John Hopkins University, Baltimore, MD, United States of America.
| | - Angad Uppal
- John Hopkins University, Baltimore, MD, United States of America.
| | - Jonathan Strong
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Tina Nguyen
- University of Maryland at College Park, College Park, MD, United States of America.
| | - Kanisha Pope
- University of Maryland at College Park, College Park, MD, United States of America
| | - Ryne Jenkins
- R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Heba Al Rebh
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - David Gatz
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Wan-Tsu Chang
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America; R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America; R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, United States of America.
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Li LJ, Yang Y, Guan BY, Chen Q, Wang AX, Wang YJ, Zhang N, Wang CX. Insomnia is associated with increased mortality in patients with first-ever stroke: a 6-year follow-up in a Chinese cohort study. Stroke Vasc Neurol 2018; 3:197-202. [PMID: 30637124 PMCID: PMC6312128 DOI: 10.1136/svn-2017-000136] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/19/2018] [Accepted: 03/04/2018] [Indexed: 01/24/2023] Open
Abstract
Objective Insomnia is a highly prevalent disorder among patients suffering from stroke. The association between insomnia and stroke mortality is less studied, particularly using the latest diagnostic criteria. The current study examined the relationship between insomnia and mortality among patients with first-evonal hazard models were used to calculate HRs for stroke er stroke in China. Methods Patients with acute cerebrovascular diseases (stroke) were recruited from 56 hospitals in mainland China. Insomnia was defined as difficulty falling asleep, or difficulty staying asleep or waking up early, for at least two consecutive visits. Demographic data, medical history and clinical data were collected. Four follow-up visits occurred within the first year after stroke, and the last follow-up call was conducted 6 years later. Cox proportional hazard models were used to calculate HRs for stroke mortality. Results Insomnia was reported by 38.4% (489/1273) of patients at baseline. During the 6 years of follow-up, after adjusting for all confounders, insomnia was found to be associated with increased mortality (HR=1.66, 95% CI 1.10 to 2.48). Old age (HR=1.08, 95% CI 1.06 to 1.10), stroke recurrence in the first year of follow-up (HR=2.53, 95% CI 1.48 to 4.31) and stroke survivors with hypertension (HR=1.62, 95% CI 1.04 to 2.53) had substantially higher risk of mortality. Conclusions Besides old age, stroke recurrence in the first year of follow-up and hypertension, insomnia is associated with increased risk of mortality in patients with first-ever stroke in China. More studies about prompt and efficient interventions for insomnia are expected in the future. Trial registration number rctn62169508.
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Affiliation(s)
- Li-Jun Li
- Department of Neuropsychiatry, Behavioral Neurology and Sleep Center, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yang Yang
- Department of Neuropsychiatry, Behavioral Neurology and Sleep Center, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Bo-Yuan Guan
- Department of Neuropsychiatry, Behavioral Neurology and Sleep Center, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qi Chen
- Department of Neuropsychiatry, Behavioral Neurology and Sleep Center, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - An-Xin Wang
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yong-Jun Wang
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Ning Zhang
- Department of Neuropsychiatry, Behavioral Neurology and Sleep Center, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chun-Xue Wang
- Department of Neuropsychiatry, Behavioral Neurology and Sleep Center, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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