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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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Al-Salihi MM, Gillani SA, Saha R, Jumaa MA, Zaidi SF, Siddiq F, Gomez CR, Mazhigi M, Qureshi AI. Systolic blood pressure reduction strategies in acute ischemic stroke patients following endovascular thrombectomy: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107724. [PMID: 38636831 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107724] [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: 12/22/2023] [Revised: 04/09/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND AIMS There is no clear consensus on ideal systolic blood pressure (SBP) target post-endovascular thrombectomy (EVT) in patients with acute ischemic stroke. This study intends to investigate the relationship between reducing SBP and clinical outcomes and to determine the therapeutic efficacy of moderate and intensive SBP reduction post EVT. METHODS A comprehensive search was conducted across five electronic databases to identify studies relevant to our analysis. Data from these studies were then analyzed using pooled relative risk (RR) along with their corresponding 95 % confidence intervals (CI) for our categorical outcomes. functional independence at 90 days post-EVT was defined as a modified Rankin score (mRS) 0-2. RESULTS Our meta-analysis included eight studies with 2922 patients: 1376 patients were treated with intensive SBP reduction, 306 with moderate SBP reduction, and 1243 with standard SBP reduction. There was no difference in the risk of functional independence at 90 days post-EVT with both intensive-SBP reduction (target 120-140 mmHg, relative risk (RR) =1.05, 95 % CI 0.82, 1.34, p = 0.72) and moderate-SBP reduction (>160 mm Hg) (RR= 0.95, 95 % CI 0.69, 1.31, p = 0.76) compared with standard SBP reduction (>180 mm Hg). The risk of symptomatic intracranial hemorrhage (sICH) did not significantly differ between standard-SBP reduction and intensive-SBP reduction (RR = 0.93, 95 % CI 0.66, 1.31, p = 0.36) or moderate-SBP reduction (0.72 (95 % CI [0.28, 1.87], p = 0.50) groups, respectively. Intensive-SBP reduction significantly decreased the risk of hemicraniectomy. CONCLUSIONS We did not identify any difference in functional independence at 90 days in acute ischemic stroke patients with either intensive-SBP reduction or moderate-SBP reduction compared with standard SBP reduction post-EVT.
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Affiliation(s)
- Mohammed Maan Al-Salihi
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA.
| | - Syed A Gillani
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Ram Saha
- Department of Neurology, Schoold of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mouhammad A Jumaa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Syed F Zaidi
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Mikael Mazhigi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Adnan I Qureshi
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
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Zhang K, Wang X, Wu Y, Liang F, Hou X, Zhang Z, Wang A, Liu L, Han R. Intensive Versus Standard Blood Pressure Management after Endovascular Therapy for Acute Ischemic Stroke: A Systematic Review and Meta-analysis. J Neurosurg Anesthesiol 2024:00008506-990000000-00100. [PMID: 38557945 DOI: 10.1097/ana.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/09/2024] [Indexed: 04/04/2024]
Abstract
Prospective clinical studies on blood pressure (BP) management targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) have recently been published. Our objective was to assess the impact on clinical outcomes of BP management guided by established systolic BP (SBP) targets within the first 24 hours after successful EVT. Four randomized controlled trials (RCTs) including 1556 participants across 5 SBP target settings identified from 5 databases up to September 6, 2023 were included in this systematic review and meta-analysis. All the intensive SBP target groups in these RCTs were combined to facilitate head-to-head comparisons. Patients receiving intensive SBP management had lower risk of 90-day functional independence as assessed by the modified Rankin scale score (relative risk [RR], 0.81; 95% confidence interval [CI], 0.72 to 0.91; I2, 12%), excellent outcomes (RR,0.86; 95% CI, 0.75 to 0.99; I2, 7%), favorable outcomes (RR, 0.85; 95% CI, 0.78 to 0.92; I2, 0%), and quality of life (standardized mean difference, -0.22; 95% CI, -0.35 to -0.10; I2,0%). There were no differences in the probability of any intracerebral hemorrhage (RR, 1.04; 95% CI, 0.92 to 1.19; I2,0%), symptomatic intracerebral hemorrhage (RR, 1.10; 95% CI, 0.76 to 1.60; I2, 0%), stroke-related death (RR, 1.16; 95% CI, 0.80 to 1.68; I2, 0%), or parenchymal hematoma (RR, 1.71; 95% CI, 0.74 to 3.98; I2, 47%) between SBP targets. This meta-analysis provides evidence from RCTs suggesting that intensive SBP control (target<160 mm Hg) may be detrimental to clinical outcomes in AIS patients with successful reperfusion after EVT.
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Affiliation(s)
- Kangda Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Xinyan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Youxuan Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Fa Liang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Xuan Hou
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Zihui Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Anxin Wang
- Department of Clinical Epidemiology and Clinical Trial, Beijing Tiantan Hospital, Capital Medical University
| | - Liping Liu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
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Robbe MMQ, Pinckaers FME, Olthuis SGH, Bos MJ, van Oostenbrugge RJ, van Zwam WH, Staals J, Postma AA. Procedural Blood Pressure and Intracranial Hemorrhage on Dual-Energy Computed Tomography After Endovascular Stroke Treatment. Cardiovasc Intervent Radiol 2024; 47:483-491. [PMID: 38062172 DOI: 10.1007/s00270-023-03619-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/06/2023] [Indexed: 04/07/2024]
Abstract
PURPOSE Optimal systolic blood pressure (SBP) management during endovascular treatment (EVT) for acute ischemic stroke remains a topic of debate. Though BP is associated with worse functional outcome, the relationship between BP and post-procedural intracranial hemorrhage (ICH) is less well-known. We aimed to investigate the association between BP during EVT and post-procedural ICH on dual-energy CT (DECT). METHODS We included all patients who underwent EVT for an anterior circulation large vessel occlusion between 2010 and 2019, and received DECT < 3 h post-EVT. All BP measurements during the EVT procedure were used to calculate mean arterial pressure (MAPmean), mean SBP (SBPmean), and SBPmax-min (highest minus lowest). ICH was assessed using virtual post-procedural unenhanced DECT reconstructions and classified as intraparenchymal or extraparenchymal. Symptomatic ICH was scored according to the Heidelberg criteria. The association between different BP parameters and ICH was assessed using multivariable logistic regression. RESULTS We included 478 patients. Seventy-six patients (16%) demonstrated ICH on DECT, of which 26 (34%) were intraparenchymal. Symptomatic intraparenchymal and extraparenchymal ICH occurred in 10 (38%) and 4 (8%) patients. SBPmax, SBPmean, and MAPmean were associated with intraparenchymal ICH with an adjusted odds ratio of 1.19 (95%CI, 1.02-1.39), 1.22 (95%CI, 1.03-1.46), and 1.40 (95%CI, 1.09-1.81) per 10 mmHg, while BP was not significantly associated with extraparenchymal ICH. BP did not differ between asymptomatic and symptomatic ICH. CONCLUSION Procedural BP is associated with intraparenchymal ICH on post-EVT DECT but not with extraparenchymal ICH. Future studies should evaluate whether individual procedural BP management reduces post-EVT ICH and improves clinical outcome.
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Affiliation(s)
- M M Q Robbe
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands.
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - F M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - S G H Olthuis
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M J Bos
- Departments of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - W H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J Staals
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, P. Debeyelaan 25, 6229HX, Maastricht, The Netherlands
- School for Mental Health and Sciences (MHENS), Maastricht University, Maastricht, The Netherlands
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Dammavalam V, Lin S, Nessa S, Daksla N, Stefanowski K, Costa A, Bergese S. Neuroprotection during Thrombectomy for Acute Ischemic Stroke: A Review of Future Therapies. Int J Mol Sci 2024; 25:891. [PMID: 38255965 PMCID: PMC10815099 DOI: 10.3390/ijms25020891] [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: 11/30/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Stroke is a major cause of death and disability worldwide. Endovascular thrombectomy has been impactful in decreasing mortality. However, many clinical results continue to show suboptimal functional outcomes despite high recanalization rates. This gap in recanalization and symptomatic improvement suggests a need for adjunctive therapies in post-thrombectomy care. With greater insight into ischemia-reperfusion injury, recent preclinical testing of neuroprotective agents has shifted towards preventing oxidative stress through upregulation of antioxidants and downstream effectors, with positive results. Advances in multiple neuroprotective therapies, including uric acid, activated protein C, nerinetide, otaplimastat, imatinib, verapamil, butylphthalide, edaravone, nelonemdaz, ApTOLL, regional hypothermia, remote ischemic conditioning, normobaric oxygen, and especially nuclear factor erythroid 2-related factor 2, have promising evidence for improving stroke care. Sedation and blood pressure management in endovascular thrombectomy also play crucial roles in improved stroke outcomes. A hand-in-hand approach with both endovascular therapy and neuroprotection may be the key to targeting disability due to stroke.
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Affiliation(s)
- Vikalpa Dammavalam
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Sandra Lin
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Sayedatun Nessa
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Neil Daksla
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Kamil Stefanowski
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Ana Costa
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
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Sheriff FG, Ahmad A, Inam ME, Khatri R, Maud A, Rodriguez GJ. A systematic review on the assessment of cerebral autoregulation in patients with Large Vessel Occlusion. Front Neurol 2023; 14:1287873. [PMID: 38046584 PMCID: PMC10693431 DOI: 10.3389/fneur.2023.1287873] [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: 09/02/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
As the majority of large vessel occlusion (LVO) patients are not treated with revascularization therapies or efficiently revascularized, complementary management strategies are needed. In this article we explore the importance of cerebral autoregulation (CA) assessment in the prediction and/or modification of infarct growth and hemorrhagic transformation. In patients with LVO, these are important factors that affect prognosis. A systematic search of the PubMed, EMBASE databases and a targeted Google search was conducted, resulting in the inclusion of 34 relevant articles. There is an agreement that CA is impaired in patients with LVO; several factors have been identified such as time course, revascularization status, laterality, disease subtype and location, some of which may be potentially modifiable and affect outcomes. The personalized CA assessment of these patients suggests potential for better understanding of the inter-individual variability. Further research is needed for the development of more accurate, noninvasive techniques for continuous monitoring and personalized thresholds for CA.
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Affiliation(s)
- Faheem G. Sheriff
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | | | - Mehmet E. Inam
- University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rakesh Khatri
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Alberto Maud
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Gustavo J. Rodriguez
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
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Jiang X, Gao L, Wang J, Bao J, Fang J, He L. Collateral Status Modification of the Association Between Blood Pressure Variation Within 72 Hours After Endovascular Treatment and Clinical Outcome in Acute Ischemic Stroke: A Retrospective Cohort Study. Clin Interv Aging 2023; 18:1491-1499. [PMID: 37720841 PMCID: PMC10503512 DOI: 10.2147/cia.s424347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023] Open
Abstract
Background Blood pressure variation and collateral status have been reported to be associated with clinical outcome in patients with acute ischemic stroke who received endovascular treatment; however, the relationship between blood pressure variation within 72 hours after EVT and clinical outcome in different collateral status remains unclear. Methods Acute ischemic stroke patients due to large vessel occlusion with EVT were retrospectively enrolled. We classified participants into poor collateral (ASITN/SIR grade <2) and good collateral subgroups (ASITN/SIR grade ≥2). The primary outcome was unfavorable neurological outcome defined as a 3-month modified Rankin Scale (mRS) score ≥2. The interactive effect was tested to determine the influence of collateral status on the association between BP variation and clinical outcome. Results A total of 545 patients were included. The poor collateral subgroup was detected in 198 patients with an average age of 70.2 years. The association between BP variation and primary outcome did not differ under different collateral status (P for interaction >0.05). However, the association between the mean and coefficient of variation (CV) values of DBP and 3-month mortality was significantly discrepant under different collateral status (P for interaction <0.05). In the good collateral subgroup, higher mean DBP was associated with a lower risk of 3-month mortality (OR 0.95, 95% CI 0.91-1, P = 0.033) compared with the poor subgroup (OR 1.04, 95% CI 0.97-1.1, P = 0.286). In addition, a higher CV of DBP was associated with a higher risk of 3-month mortality (OR 1.24, 95% CI 1.13-1.36, P < 0.01) compared with poor status (OR 1.08, 95% CI 0.94-1.23, P=0.275). Conclusion For patients who received EVT with good collateral status, increased CV of DBP was significantly associated with higher 3-month mortality, while higher mean DBP within 72 h after EVT was associated with a decrease in 3-month mortality.
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Affiliation(s)
- Xin Jiang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Lijie Gao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Jian Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Jiajia Bao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
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Mistry EA, Hart KW, Davis LT, Gao Y, Prestigiacomo CJ, Mittal S, Mehta T, LaFever H, Harker P, Wilson-Perez HE, Beasley KA, Krothapalli N, Lippincott E, Stefek H, Froehler M, Chitale R, Fusco M, Grossman A, Shirani P, Smith M, Jaffa MN, Yeatts SD, Albers GW, Wanderer JP, Tolles J, Lindsell CJ, Lewis RJ, Bernard GR, Khatri P. Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial. JAMA 2023; 330:821-831. [PMID: 37668620 PMCID: PMC10481231 DOI: 10.1001/jama.2023.14330] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/11/2023] [Indexed: 09/06/2023]
Abstract
Importance The effects of moderate systolic blood pressure (SBP) lowering after successful recanalization with endovascular therapy for acute ischemic stroke are uncertain. Objective To determine the futility of lower SBP targets after endovascular therapy (<140 mm Hg or 160 mm Hg) compared with a higher target (≤180 mm Hg). Design, Setting, and Participants Randomized, open-label, blinded end point, phase 2, futility clinical trial that enrolled 120 patients with acute ischemic stroke who had undergone successful endovascular therapy at 3 US comprehensive stroke centers from January 2020 to March 2022 (final follow-up, June 2022). Intervention After undergoing endovascular therapy, participants were randomized to 1 of 3 SBP targets: 40 to less than 140 mm Hg, 40 to less than 160 mm Hg, and 40 to 180 mm Hg or less (guideline recommended) group, initiated within 60 minutes of recanalization and maintained for 24 hours. Main Outcomes and Measures Prespecified multiple primary outcomes for the primary futility analysis were follow-up infarct volume measured at 36 (±12) hours and utility-weighted modified Rankin Scale (mRS) score (range, 0 [worst] to 1 [best]) at 90 (±14) days. Linear regression models were used to test the harm-futility boundaries of a 10-mL increase (slope of 0.5) in the follow-up infarct volume or a 0.10 decrease (slope of -0.005) in the utility-weighted mRS score with each 20-mm Hg SBP target reduction after endovascular therapy (1-sided α = .05). Additional prespecified futility criterion was a less than 25% predicted probability of success for a future 2-group, superiority trial comparing SBP targets of the low- and mid-thresholds with the high-threshold (maximum sample size, 1500 with respect to the utility-weighted mRS score outcome). Results Among 120 patients randomized (mean [SD] age, 69.6 [14.5] years; 69 females [58%]), 113 (94.2%) completed the trial. The mean follow-up infarct volume was 32.4 mL (95% CI, 18.0 to 46.7 mL) for the less than 140-mm Hg group, 50.7 mL (95% CI, 33.7 to 67.7 mL), for the less than 160-mm Hg group, and 46.4 mL (95% CI, 24.5 to 68.2 mL) for the 180-mm Hg or less group. The mean utility-weighted mRS score was 0.51 (95% CI, 0.38 to 0.63) for the less than 140-mm Hg group, 0.47 (95% CI, 0.35 to 0.60) for the less than 160-mm Hg group, and 0.58 (95% CI, 0.46 to 0.71) for the high-target group. The slope of the follow-up infarct volume for each mm Hg decrease in the SBP target, adjusted for the baseline Alberta Stroke Program Early CT score, was -0.29 (95% CI, -0.81 to ∞; futility P = .99). The slope of the utility-weighted mRS score for each mm Hg decrease in the SBP target after endovascular therapy, adjusted for baseline utility-weighted mRS score, was -0.0019 (95% CI, -∞ to 0.0017; futility P = .93). Comparing the high-target SBP group with the lower-target groups, the predicted probability of success for a future trial was 25% for the less than 140-mm Hg group and 14% for the 160-mm Hg group. Conclusions and Relevance Among patients with acute ischemic stroke, lower SBP targets less than either 140 mm Hg or 160 mm Hg after successful endovascular therapy did not meet prespecified criteria for futility compared with an SBP target of 180 mm Hg or less. However, the findings suggested a low probability of benefit from lower SBP targets after endovascular therapy if tested in a future larger trial. Trial Registration ClinicalTrials.gov Identifier: NCT04116112.
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Affiliation(s)
- Eva A. Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Kimberly W. Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Larry T. Davis
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yue Gao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Shilpi Mittal
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tapan Mehta
- Ayer Neuroscience Institute, Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Hayden LaFever
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pablo Harker
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Kalli A. Beasley
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Neeharika Krothapalli
- Ayer Neuroscience Institute, Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Emily Lippincott
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Heather Stefek
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Froehler
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rohan Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aaron Grossman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Peyman Shirani
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Matthew Smith
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Matthew N. Jaffa
- Ayer Neuroscience Institute, Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Sharon D. Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | | | - Jonathan P. Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Juliana Tolles
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- Duke Clinical Research Institute, Durham, North Carolina
| | - Roger J. Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California
- Statistical Editor, JAMA
| | - Gordon R. Bernard
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
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9
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Zhou J, Samara H, Ebrahim A, Kinariwala J, Mohamed W. Blood pressure variability and short-term outcomes after mechanical thrombectomy in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107197. [PMID: 37267795 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107197] [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: 11/22/2022] [Revised: 05/13/2023] [Accepted: 05/19/2023] [Indexed: 06/04/2023] Open
Abstract
OBJECTIVES There is limited data evaluating effects of post-mechanical thrombectomy (MT) blood pressure (BP) control on short-term clinical outcomes in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). We aim to investigate the association of BP variations, after MT, with stroke early outcomes. MATERIALS AND METHODS A retrospective study was conducted on AIS patients with LVO undergoing MT at a tertiary center over 3.5 years. Hourly BP data was recorded within the first 24- and 48-hours post-MT. BP variability was expressed as the interquartile range (IQR) of BP distribution. Short-term favorable outcome was defined as modified Rankin scale (mRS) 0-3, discharge to home or inpatient rehabilitation facility (IRF). RESULTS Of the 95 enrolled subjects, 37(38.9%) had favorable outcomes at discharge and 8 (8.4%) died. After adjustment for confounders, an increase in IQR of systolic blood pressure (SBP) within the first 24 hours after MT revealed a significant inverse association with favorable outcomes (OR 0.43, 95% CI [0.19, 0.96], p = 0.039). Increased median MAP within the first 24 hours after MT correlated with favorable outcomes (OR 1.75, 95% CI [1.09, 2.83], p = 0.021). Subgroup analysis redemonstrated significant inverse association between increased SBP IQR and favorable outcomes (OR 0.48, 95% CI [0.21, 0.97], p = 0.042) among patients with successful revascularization. CONCLUSIONS Post-MT high SBP variability was associated with worse short-term outcomes in AIS patients with LVO regardless of recanalization status. MAP values may be used as indicators for functional prognosis.
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Affiliation(s)
- Jiping Zhou
- Department of Neurology, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Heba Samara
- Department of Neurology, Kymera Independent Physicians, Roswell, NM, USA
| | - Ali Ebrahim
- Department of Neurology, Golden Valley Memorial Healthcare, Clinton, MO, USA
| | - Jay Kinariwala
- Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Wazim Mohamed
- Department of Neurology, Wayne State University/Detroit Medical Center, Detroit, MI, USA.
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10
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Zhou Y, Chen Z, Fang J, Huang G. Blood pressure targets for acute ischemic stroke patients following endovascular thrombectomy: A meta-analysis. Clin Neurol Neurosurg 2023; 231:107835. [PMID: 37354634 DOI: 10.1016/j.clineuro.2023.107835] [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: 04/22/2023] [Revised: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE The objective of this meta-analysis was to explore the impact of different blood pressure levels following endovascular therapy on clinical outcomes, including safety and efficacy in acute ischemic stroke (AIS) patients. METHODS A systematic search was performed on PubMed, Embase, Cochrane Library, and Web of Science databases, covering studies published before February 1, 2023. Our primary outcomes were 90-day mRs 0-2 score, 90-day mortality, incidence of symptomatic intracranial hemorrhage(sICH), and hemicraniectomy. RESULTS The incidence of 90-day mRs= 2 score was no significant difference between different blood pressure values (OR=1.37, 95 % CI [0.82, 2.29], p = 0.23) with heterogeneity (I2 =85 %, p < 0.001). Subgroup analysis indicated that when the blood pressure targets were SBP< 140 mmHg (OR=1.73, 95 % CI [1.04, 2.90], p = 0.04) with heterogeneity (I2 =37 %, p = 0.20), and SBP< 130 mmHg (OR=1.58, 95 % CI [0.53, 4.70], p = 0.41) with heterogeneity (I2 =80 %, p = 0.02), there were statistic differences in the incidence of 90-day modified mRs 0-2 score. Regarding 90-day mortality, there was no significant difference between different blood pressure values (OR=0.75, 95 % CI [0.47, 1.21], p = 0.24; I2 =69 %, p = 0.007). As for the incidence of sICH, the difference was not statistically significant (OR = 0.82, 95 % CI [0.61, 1.09], p = 0.17; I2 =24 %, p = 0.26). However, subgroup analysis was performed due to different blood pressure values, and it was found that when the blood pressure targets were SBP<140 mmHg (OR=0.49, 95 % CI [0.28, 0.87], p = 0.02) and SBP<120 mmHg (OR = 0.84, 95 % CI [0.58, 1.23], p = 0.37), there were statistic differences in the incidence of sICH with SBP<140 mmHg. Furthermore, SBP<140 mmHg was associated with a lower incidence of hemicraniectomy (OR = 0.30, 95 % CI [0.15, 0.58], p<0.001). PROSPERO Register Number: CRD42022376706 CONCLUSION: The present meta-analysis findings indicate that intensive treatment is advantageous for achieving successful reperfusion in acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT). For different blood pressure targets (SBP < 140mmhg, SBP < 130mmhg, SBP < 120mmhg), with a reduction in systolic blood pressure (SBP) to less than 140 mmHg appearing to confer the greatest benefit. Furthermore, this study provides a significant blood pressure target that could inform the design of future multicentre, open-label, blinded-endpoint, randomized controlled trials.
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Affiliation(s)
- Yitao Zhou
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou City, Zhejiang Province, China
| | - Zixi Chen
- Department of Emergency Medcine, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou City, China
| | - Jinyan Fang
- Department of Emergency Medcine, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou City, China
| | - Ganying Huang
- Department of Emergency Medcine, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou City, China.
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11
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Zubair AS, Sheth KN. Hemorrhagic Conversion of Acute Ischemic Stroke. Neurotherapeutics 2023; 20:705-711. [PMID: 37085684 PMCID: PMC10275827 DOI: 10.1007/s13311-023-01377-1] [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] [Accepted: 04/04/2023] [Indexed: 04/23/2023] Open
Abstract
Stroke is a leading cause of morbidity and mortality worldwide; a serious complication of ischemic stroke is hemorrhagic transformation. Current treatment of acute ischemic stroke includes endovascular thrombectomy and thrombolytic therapy. Both of these treatment options are linked with increased risks of hemorrhagic conversion. The diagnosis and timely management of patients with hemorrhagic conversion is critically important to patient outcomes. This review aims to discuss hemorrhagic conversion of acute ischemic stroke including discussion of the pathophysiology, review of risk factors, imaging considerations, and treatment of patients with hemorrhagic conversion.
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Affiliation(s)
- Adeel S Zubair
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, USA
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12
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De Georgia M, Bowen T, Duncan KR, Chebl AB. Blood pressure management in ischemic stroke patients undergoing mechanical thrombectomy. Neurol Res Pract 2023; 5:12. [PMID: 36991520 PMCID: PMC10061853 DOI: 10.1186/s42466-023-00238-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
The relationship between presenting blood pressure in acute ischemic stroke patients and outcome is complex. Several studies have demonstrated a U-shaped curve with worse outcomes when blood pressure is high or low. The American Heart Association/American Stroke Association guidelines recommend values of blood pressure < 185/110 mmHg in patients treated with intravenous t-PA and "permissive hypertension" up to 220/120 mmHg in those not treated with intravenous t-PA. The optimal blood pressure target is less clear in patients undergoing mechanical thrombectomy. Before thrombectomy, the guidelines recommend a blood pressure < 185/110 mmHg though patients with even lower systolic blood pressures may have better outcomes. During and after thrombectomy, the guidelines recommend a blood pressure < 180/105 mmHg. However, several studies have suggested that during thrombectomy the primary goal should be to prevent significant low blood pressure (e.g., target systolic blood pressure > 140 mmHg or MAP > 70 mmHg). After thrombectomy, the primary goal should be to prevent high blood pressure (e.g., target systolic blood pressure < 160 mmHg or MAP < 90 mmHg). To make more specific recommendations, large, randomized-control studies are needed that address factors such as the baseline blood pressure, timing and degree of revascularization, status of collaterals, and estimated risk of reperfusion injury.
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Affiliation(s)
- Michael De Georgia
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Theodore Bowen
- Department of Neurology, MetroHealth Medical Center, Cleveland, OH, USA
| | - K Rose Duncan
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alex Bou Chebl
- Department of Neurology, Henry Ford Medical Center, Detroit, MI, USA
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13
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Da Ros V, Duggento A, Cavallo AU, Bellini L, Pitocchi F, Toschi N, Mascolo AP, Sallustio F, Di Giuliano F, Diomedi M, Floris R, Garaci F, Zeleňák K, Maestrini I. Can machine learning of post-procedural cone-beam CT images in acute ischemic stroke improve the detection of 24-h hemorrhagic transformation? A preliminary study. Neuroradiology 2023; 65:599-608. [PMID: 36280607 DOI: 10.1007/s00234-022-03070-0] [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: 08/05/2022] [Accepted: 10/12/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Hemorrhagic transformation (HT) is an independent predictor of unfavorable outcome in acute ischemic stroke (AIS) patients undergoing endovascular thrombectomy (EVT). Its early identification could help tailor AIS management. We hypothesize that machine learning (ML) applied to cone-beam computed tomography (CB-CT), immediately after EVT, improves performance in 24-h HT prediction. METHODS We prospectively enrolled AIS patients undergoing EVT, post-procedural CB-CT, and 24-h non-contrast CT (NCCT). Three raters independently analyzed imaging at four anatomic levels qualitatively and quantitatively selecting a region of interest (ROI) < 5 mm2. Each ROI was labeled as "hemorrhagic" or "non-hemorrhagic" depending on 24-h NCCT. For each level of CB-CT, Mean Hounsfield Unit (HU), minimum HU, maximum HU, and signal- and contrast-to-noise ratios were calculated, and the differential HU-ROI value was compared between both hemispheres. The number of anatomic levels affected was computed for lesion volume estimation. ML with the best validation performance for 24-h HT prediction was selected. RESULTS One hundred seventy-two ROIs from affected hemispheres of 43 patients were extracted. Ninety-two ROIs were classified as unremarkable, whereas 5 as parenchymal contrast staining, 29 as ischemia, 7 as subarachnoid hemorrhages, and 39 as HT. The Bernoulli Naïve Bayes was the best ML classifier with a good performance for 24-h HT prediction (sensitivity = 1.00; specificity = 0.75; accuracy = 0.82), though precision was 0.60. CONCLUSION ML demonstrates high-sensitivity but low-accuracy 24-h HT prediction in AIS. The automated CB-CT imaging evaluation resizes sensitivity, specificity, and accuracy rates of visual interpretation reported in the literature so far. A standardized quantitative interpretation of CB-CT may be warranted to overcome the inter-operator variability.
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Affiliation(s)
- Valerio Da Ros
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Andrea Duggento
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Armando Ugo Cavallo
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Luigi Bellini
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Francesca Pitocchi
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Nicola Toschi
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Alfredo Paolo Mascolo
- Stroke Center, Department of Systems Medicine, University Hospital of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Fabrizio Sallustio
- Stroke Center, Department of Systems Medicine, University Hospital of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Francesca Di Giuliano
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Marina Diomedi
- Stroke Center, Department of Systems Medicine, University Hospital of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Roberto Floris
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Francesco Garaci
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03659, Martin, Slovakia
| | - Ilaria Maestrini
- Stroke Center, Department of Systems Medicine, University Hospital of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy.
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14
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Song L, Yang P, Zhang Y, Zhang X, Chen X, Li Y, Shen H, Zhang L, Li Z, Zhang Y, Xing P, Zhang P, Zhou Y, Ren X, Billot L, Wang X, Parsons MW, Butcher K, Campbell B, Robinson T, Goyal M, Dippel D, Roos Y, Majoie C, Liu J, Anderson CS. The second randomized controlled ENhanced Control of Hypertension ANd Thrombectomy strokE stuDy (ENCHANTED2): Protocol and progress. Int J Stroke 2023; 18:364-369. [PMID: 35924814 DOI: 10.1177/17474930221120345] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Uncertainty exists over the optimal level of blood pressure (BP) after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). OBJECTIVES We aim to determine the effectiveness and safety of intensive BP-lowering following MT reperfusion of large-vessel occlusion (LVO)-related AIS. DESIGN The second ENhanced Control of Hypertension ANd Thrombolysis strokE stuDy (ENCHANTED2) is an investigator-initiated, multicenter, prospective, randomized, open, blinded-endpoint (PROBE) trial of intensive systolic BP (SBP) control in reperfused (extended treatment in cerebral infarction (eTICI) classification 2b/2c/3) LVO-AIS patients with persistent hypertension (SBP ⩾ 140 mmHg) at 60+ sites in China, and Australia and the United Kingdom. Eligible patients are centrally randomly allocated to more- (target SBP ⩽ 120 mmHg within 1 h) or less-intensive (target SBP 140-180 mmHg) BP management, to be maintained for 72 h. Primary outcome is an ordinal shift analysis of scores on the modified Rankin scale (mRS) at 90 days. Sample size of 2257 patients provides 90% power to detect a 6.5% absolute reduction in poor outcome from more-intensive BP-lowering using ordinal logistic regression. PROGRESS Recruitment started in China in July 2020. At a meeting of the independent Data and Safety Monitoring Board in March 2022 to review primary outcome data available for 347 patients, they recommended suspension of recruitment due to safety concerns in the more-intensive group; which was implemented by the Trial Steering Committee (TSC) with 817 randomized patients only in China. The TSC then stopped recruitment after the safety concerns persisted on further review of the data in June 2022. The TSC will make a decision on restarting the trial with modification of the protocol when the results are made public. DISCUSSION ENCHANTED2 will provide further randomized evidence on the role of intensive BP-lowering after reperfusion in MT-treated AIS patients. TRIAL REGISTRATION ClinicalTrials.gov NCT04140110; registered 25 October 2019.
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Affiliation(s)
- Lili Song
- The George Institute for Global Health China, Beijing, China.,The George Institute for Global Health, Faculty of Medicine, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoxi Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoying Chen
- The George Institute for Global Health China, Beijing, China.,The George Institute for Global Health, Faculty of Medicine, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Yunke Li
- The George Institute for Global Health China, Beijing, China
| | - Hongjian Shen
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zifu Li
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ping Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yihan Zhou
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xinwen Ren
- The George Institute for Global Health China, Beijing, China
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Mark W Parsons
- Ingham Institute for Applied Medical Research, Liverpool Hospital, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Ken Butcher
- Prince of Wales Clinical School, The University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Bruce Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Mayank Goyal
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Diederik Dippel
- Department of Neurology, Erasmus MC, Rotterdam, The Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Craig S Anderson
- The George Institute for Global Health China, Beijing, China.,The George Institute for Global Health, Faculty of Medicine, The University of New South Wales (UNSW), Sydney, NSW, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
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15
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Upadhyaya P, Mehta A, Luby M, Ansari S, Lynch JK, Hsia AW, Latour LL, Kim Y. Good outcome associated with blood-brain barrier disruption and lower blood pressure after endovascular therapy. J Stroke Cerebrovasc Dis 2023; 32:106870. [PMID: 36434858 PMCID: PMC9825643 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To evaluate the association between post-endovascular thrombectomy (EVT) blood-brain barrier (BBB) disruption on MRI or CT and average systolic blood pressure (SBP) with favorable 90-day functional outcome. Observational studies have found elevated SBP associated with worse outcomes post-EVT, while recent randomized trials found no difference in targeted BP reduction. There may be a subgroup of patients who benefit from targeted BP reduction post-EVT. METHODS This is a single-center study of 1) anterior large vessel occlusion stroke patients treated with EVT from 2015 to 2021, 2) achieved mTICI grade 2b or 3. Hyperintense acute reperfusion marker (HARM), hemorrhagic transformation (HT), and midline shift at 3 h post-EVT and 24 h imaging were assessed independently by multiple raters. Binary logistic regression models were used to determine the association of post-EVT SBP with outcomes. BBB disruption was defined as HT or HARM on 3h post-EVT imaging. RESULTS Of 103 patients, those with SBP 100-129 versus SBP 130-160 found no significant difference in favorable 90-day outcome (64% vs. 46%, OR 2.11, 95% CI 0.78-5.76, p=0.143). However, among 71 patients with BBB disruption, a significant difference in favorable outcome of 64% in SBP 100-129 vs. 39% in SBP 130-160 group (OR 5.93, 95% CI 1.50-23.45, p=0.011) was found. There was no difference in symptomatic ICH, 90-day mortality, midline shift (≥5 mm), and hemicraniectomy, between BP or BBB groups. CONCLUSIONS BBB disruption on 3h post-EVT imaging and lower SBP was associated with favorable outcome. This imaging finding may guide targeted BP therapy and suggests need for a randomized control trial.
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Affiliation(s)
- Parth Upadhyaya
- Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA.
| | - Amit Mehta
- Department of Neurology, Georgetown University School of Medicine, Washington, D.C., USA
| | - Marie Luby
- Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA
| | - Saeed Ansari
- Department of Neurology, Inova Health, Fairfax, VA, USA
| | - John K Lynch
- Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA
| | - Amie W Hsia
- Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA; Department of Neurology, Georgetown University School of Medicine, Washington, D.C., USA; Comprehensive Stroke Center, MedStar Washington Hospital Center, Washington, D.C., USA
| | - Lawrence L Latour
- Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA
| | - Yongwoo Kim
- Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA; Department of Neurology, Georgetown University School of Medicine, Washington, D.C., USA; Comprehensive Stroke Center, MedStar Washington Hospital Center, Washington, D.C., USA
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16
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Liu S, Zhuang S, Li M, Zhu J, Zhang Y, Hu H. Relationship between sarcopenia and sleep status in female patients with mild to moderate Alzheimer's disease. Psychogeriatrics 2023; 23:94-107. [PMID: 36403982 DOI: 10.1111/psyg.12908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 10/09/2022] [Accepted: 10/20/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sleep disorders and sarcopenia could contribute to the development of Alzheimer's disease (AD), which are risk factors that rapidly deteriorate cognitive functions. However, few studies have evaluated the relationship between sarcopenia and sleep disorders in female AD patients, who have a higher prevalence than male patients. This study aimed to investigate the relationship between sarcopenia and sleep status in female patients with mild to moderate AD. METHODS This cross-sectional study recruited 112 female outpatients aged between 60 and 85 years. Demographic characteristics, appendicular skeletal muscle mass index (ASMI), grip strength, and gait speed were assessed. Sarcopenia was diagnosed according to criteria of the Asian Working Group for Sarcopenia. Pittsburgh Sleep Quality Index (PSQI) assessed sleep variables. Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) assessed cognitive function. Binary logistic regression models explored the relationship between sleep variables and cognitive function and sarcopenia, adjusting for potential cofounders. RESULTS The outpatients were divided into 36 AD patients with sarcopenia (ADSa) and 76 AD patients without sarcopenia (ADNSa), with a prevalence of 32.1%. ADSa had lower ASMI, weaker grip strength, slower gait speed, a higher incidence of poor sleep quality and poorer cognitive function. Multivariate binary logistic regression analysis showed that high total scores of PSQI (odds ratio (OR) = 1.13), poor sleep quality (OR = 2.73), poor subjective sleep quality (OR = 1.83), low MMSE (OR = 0.77) and MoCA (OR = 0.76) scores were associated with high odds of sarcopenia. Compared to sleep time ≤ 15 min, >60 min (OR = 5.01) were associated with sarcopenia. Sleep duration <6 h (OR = 3.99), 8-9 h (OR = 4.48) and ≥9 h (OR = 6.33) were associated with sarcopenia compared to 7-8 h. CONCLUSIONS More sleep symptoms and cognitive impairment exist in female patients with sarcopenia. The higher total scores of PSQI, poorer subjective sleep quality, longer sleep latency, excessive and insufficient sleep duration and poorer cognitive function are associated with higher odds of sarcopenia in female patients with mild to moderate AD.
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Affiliation(s)
- Shanwen Liu
- Department of Neurology and Suzhou Clinical Research Centre of Neurological Diseases, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215004, China
| | - Sheng Zhuang
- Department of Neurology and Suzhou Clinical Research Centre of Neurological Diseases, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215004, China
| | - Meng Li
- Department of Imaging, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215004, China
| | - Jiangtao Zhu
- Department of Imaging, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215004, China
| | - Yingchun Zhang
- Department of Ultrasound, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215004, China
| | - Hua Hu
- Department of Neurology and Suzhou Clinical Research Centre of Neurological Diseases, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215004, China
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17
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Impact of leukoaraiosis or blood pressure on clinical outcome, mortality and symptomatic intracerebral hemorrhage after mechanical thrombectomy in acute ischemic stroke. Sci Rep 2022; 12:21750. [PMID: 36526650 PMCID: PMC9758212 DOI: 10.1038/s41598-022-25171-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022] Open
Abstract
We aimed to study the impact of leukoaraiosis (LA) and blood pressure (BP) on clinical outcome, mortality and symptomatic intracerebral hemorrhage (sICH) in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). We analyzed data retrospectively from 521 patients with anterior large vessel occlusion treated with MT. LA was dichotomized in 0-2 (absent-to-moderate) versus 3-4 (moderate-to-severe) according to the van Swieten scale. Various systolic (SBP) and diastolic (DBP) BP parameters during the first 24 h were collected. Multivariable logistic regressions were performed to identify predictors of a poor 90-day outcome, mortality and sICH. LA was significantly associated with poor outcome (OR 3.2; p < 0.001) and mortality (OR 3.19; p = 0.008), but not sICH (p = 0.19). Higher maximum SBP was significantly associated with poor outcome (OR per 10 mmHg increase = 1.21; p = 0.009) and lower mean DBP was a predictor of mortality (OR per 10 mmHg increase = 0.53; p < 0.001). In the univariate analysis high SBP variability was associated with poor outcome, mortality and sICH, but not in the multivariate model. There was no association between BP and sICH. Severity of LA, SBP variability, high maximum SBP and low DBP are associated with either poor outcome or mortality in AIS patients undergoing MT. However, neither LA nor BP were associated with sICH in our cohort. Thus, mechanisms of the negative impact on outcome remain unclear. Further studies on impact of BP course and its mechanisms and interventions are needed to improve outcome in patients undergoing MT.
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Luo T, Cui JS, Peng H, Xiang X, Xu Y, Yang H. Effect of blood pressure on the prognosis of acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization. Clin Neurol Neurosurg 2022; 224:107540. [PMID: 36509017 DOI: 10.1016/j.clineuro.2022.107540] [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: 08/24/2022] [Revised: 10/26/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE To explore the effect of blood pressure on the prognosis of acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization. METHODS Acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization were retrospectively collected. All patients were divided into the functional independent group and non-functional independent group, death group and non-death group based on the 90-day mRS score. Logistic regression was applied to analyze the relationship between the highest systolic blood pressure, the average systolic blood pressure, the lowest systolic blood pressure, the highest diastolic blood pressure, the average diastolic blood pressure, the lowest diastolic blood pressure in the first 24 h after admission and the functional prognosis as well as the complications after 90 days. The independent impact factors selected from regression analysis were used to investigate the blood pressure with prognostic value by receiver operating characteristic curve (ROC). RESULTS A total of 70 patients were recruited in this study. Among them, 39 cases (55.71%) were male and 31 cases (44.29%) were female, with a mean age of 61.83 ± 15.24 years old. 15 cases (21.43%) had a favorable 90-day outcome, and the other 55 cases (78.57%) had a higher mRS Score. After a 90-day follow-up, univariate analysis showed that hypertension and hyperlipidemia, highest systolic blood pressure, mean systolic blood pressure and NIHSS score were statistically significant in two groups with or without functional independence, while the NIHSS score at admission, systolic blood pressure at admission, average systolic blood pressure, highest systolic blood pressure and diastolic blood pressure were statistically significant in patients with death outcomes (P < 0.05). Multivariate regression analysis suggested that the highest systolic blood pressure was statistically significant (P < 0.05), the further ROC curve results showed the cut-off value of the highest systolic blood pressure was 180.5 mmHg, with a sensitivity of 82.35% and a specificity of 81.13%. The highest Youden's index was 0.6348. CONCLUSION For acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanalization, the appropriate reduction of blood pressure within 24 h after admission may have a positive effect on the clinical prognosis. The 90-day mortality of acute ischemic stroke patients without revascularization was independently related to the highest systolic blood pressure. The risk of death was increased when the highest systolic blood pressure was greater than 180.5 mmHg.
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Affiliation(s)
- Tao Luo
- Clinical Medical College of Guizhou Medical University, Guizhou, China
| | - Jun Shuan Cui
- Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Han Peng
- Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Xin Xiang
- Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Yuan Xu
- Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Hua Yang
- Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China..
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Vilionskis A, Gaigalaite V, Salasevicius L, Jatuzis D. Association between systolic blood pressure parameters and unexplained early neurological deterioration (UnND) in acute ischemic stroke patients treated with mechanical thrombectomy. Ther Adv Neurol Disord 2022; 15:17562864221093524. [PMID: 35747319 PMCID: PMC9210098 DOI: 10.1177/17562864221093524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Neurological deterioration (ND) after mechanical thrombectomy (MT) of acute ischemic stroke (AIS) in anterior circulation is an important complication associated with a poor outcome. Moreover, evident causes of ND may remain unexplained (UnND). Objective: We sought to evaluate the association of the systolic blood pressure (SBP) parameters before MT, during MT, and during a 24-h period after MT with UnND. Methods: We analyzed 382 MT-treated AIS patients in two stroke centers from 2017 to 2019. The patients with unsuccessful recanalization and/or with symptomatic intracerebral hemorrhage after MT were excluded. Multivariate logistic regression analysis was used to identify the SBP parameters that predict UnND. Results: There were 5.9% patients with UnND within 24 h after MT among patients with successful recanalization what comprises 4.9% of all patients who had undergone MT. SBP > 180 mmHg on admission (odds ratio (OR): 4, 95% confidence interval (CI): 1.6–10, p = 0.004) and a drop of SBP below100 mmHg during MT (OR: 4.7, 95% CI: 1.3–17, p = 0.019) were associated with UnND occurrence within 7 days without a significant association with UnND within 24 h. UnND within 7 days was predicted by the episodes of SBP exceeding the level of SBP observed before the groin puncture and occurring over the first 2 h following recanalization (OR: 5, 95% CI: 1.3–19, p = 0.021), an increase of SBP of more than 20% within 2–24 h after MT (OR: 3.4, 95% CI: 1.1–10, p = 0.035), and a drop of SBP below 100 mmHg after MT (OR: 3.2, 95% CI: 1.1–9, p = 0.039). Conclusion: The association between the SBP parameters and UnND depends on the treatment period and the time of UnND occurrence. The J/U resembling relationship between SBP and UnEND was established during a 24-h period after MT.
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Affiliation(s)
| | - Virginija Gaigalaite
- Institute of Clinical Medicine, Vilnius University, Siltnamiu 29, Vilnius 01513, Lithuania
| | | | - Dalius Jatuzis
- Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
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20
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Lagebrant C, Ramgren B, Hassani Espili A, Marañon A, Kremer C. Sex Differences in Collateral Circulation and Outcome After Mechanical Thrombectomy in Acute Ischemic Stroke. Front Neurol 2022; 13:878759. [PMID: 35665053 PMCID: PMC9160377 DOI: 10.3389/fneur.2022.878759] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Collateral circulation is known to lead to smaller infarct volume and better functional outcome after mechanical thrombectomy (MT), but studies examining sex differences in collateral circulation are scarce. The aim of this study was to investigate if collateral circulation has a different impact on outcome in women and men. Methods A single-center retrospective study of 487 patients (230 men and 257 women) treated with MT for acute ischemic stroke in the anterior cerebral circulation. Collateral circulation was assessed on computed tomography angiography images. The outcome was evaluated at 90 days according to the modified Rankin Scale (mRS). Results Women were older, median age 76 years (IQR 68-83) vs. 71 years (IQR 63–78). Stroke severity and time to recanalization were comparable. More women had moderate or good collaterals in 58.4 vs. 47.0% for men (p = 0.01). Among patients with moderate and good collaterals significantly more men (61%) were functionally independent (mRS 0–2) than women (41.5%) (p = < 0.01). This difference remained significant after correcting for age by linear weighting, 60.4 vs. 46.8% (p = 0.03). Conclusion Women had better collateral flow but showed worse functional outcomes, while good collateral flow led to better outcomes in men, even after correcting for age. Further clinical studies on peri- and post-interventional care, factors affecting recovery after hospital discharge as well as basic research on the neurovascular unit are needed to find modifiable targets to improve clinical outcomes for women.
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Affiliation(s)
| | - Birgitta Ramgren
- Department of Diagnostic Radiology, Neuroradiology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | | | | | - Christine Kremer
- Neurology Department, Department of Clinical Sciences, Skåne University Hospital Malmö, Lund University, Lund, Sweden
- *Correspondence: Christine Kremer
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21
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Anesthetic considerations for endovascular treatment of acute ischemic stroke. Can J Anaesth 2022; 69:658-673. [DOI: 10.1007/s12630-022-02224-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 05/06/2021] [Accepted: 12/08/2021] [Indexed: 01/01/2023] Open
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22
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Zhang X, Cui T, Zhu Q, Wang C, Wang A, Yang Y, Li S, Hu F, Wu B. Association of Blood Pressure Within 6 h After Endovascular Thrombectomy and Functional Outcomes in Ischemic Stroke Patients With Successful Recanalization. Front Neurol 2022; 13:860124. [PMID: 35493826 PMCID: PMC9046679 DOI: 10.3389/fneur.2022.860124] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/02/2022] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose Blood pressure in the days following endovascular thrombectomy (EVT) can influence functional outcomes of patients who have suffered an acute ischemic stroke, but whether the same is true of blood pressure during the first few hours after EVT is unclear. Methods Several blood pressure parameters were retrospectively analyzed in acute ischemic stroke patients who underwent EVT at West China Hospital from March 2016 to December 2019. Baseline blood pressure, speed of blood pressure reduction, postoperative blood pressure, degree of blood pressure reduction, and quality of blood pressure management were evaluated during the first 24 h after EVT. We explored whether these parameters during different time windows correlated significantly with patients' modified Rankin Scale (mRS) score at 90 days. Results Analysis of 163 patients showed that poor functional outcome (mRS scores 3–6) correlated significantly with higher postoperative blood pressure and worse blood pressure management during the first 6 h after EVT. Postoperative systolic blood pressure at 37 min after EVT was significantly higher in patients with poor outcome (141 mmHg) than in those with good outcome (mRS scores 0–2; 122 mmHg, p = 0.006), and systolic pressure >136 mmHg at this time point was associated with a significantly higher risk of poor outcome, before and after adjusting for other risk factors (adjusted OR 0.395, 95% CI 0.20–0.79). Conclusions Among acute ischemic patients who successfully undergo recanalization, adequate blood pressure management during the first 30–40 min after EVT may be important for ensuring good 90-day functional outcomes.
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Affiliation(s)
- Xuening Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Cui
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiange Zhu
- Second Department of Neurology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Changyi Wang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Anmo Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan Yang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Shucheng Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Fayun Hu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Fayun Hu
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Bo Wu
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23
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Petersen NH, Kodali S, Meng C, Li F, Nguyen CK, Peshwe KU, Strander S, Silverman A, Kimmel A, Wang A, Anadani M, Almallouhi E, Spiotta AM, Kim JT, Giles JA, Keyrouz SG, Farooqui M, Zevallos C, Maier IL, Psychogios MN, Liman J, Riou-Comte N, Richard S, Gory B, Wolfe SQ, Brown PA, Fargen KM, Mistry EA, Fakhri H, Mistry AM, Wong KH, de Havenon A, Nascimento FA, Kan P, Matouk C, Ortega-Gutiérrez S, Sheth KN. Blood Pressure Trajectory Groups and Outcome After Endovascular Thrombectomy: A Multicenter Study. Stroke 2022; 53:1216-1225. [PMID: 34781705 PMCID: PMC8960326 DOI: 10.1161/strokeaha.121.034408] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes. METHODS This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the modified Rankin Scale 90 days after stroke. Secondary outcomes included hemorrhagic transformation, symptomatic intracranial hemorrhage, and death. RESULTS Two thousand two hundred sixty-eight patients (mean age [±SD] 69±15, mean National Institutes of Health Stroke Scale 15±7) were included in the analysis. Five distinct SBP trajectories were observed: low (18%), moderate (37%), moderate-to-high (20%), high-to-moderate (18%), and high (6%). SBP trajectory group was independently associated with functional outcome at 90 days (P<0.0001) after adjusting for potential confounders. Patients with high and high-to-moderate SBP trajectories had significantly greater odds of an unfavorable outcome (adjusted odds ratio, 3.5 [95% CI, 1.8-6.7], P=0.0003 and adjusted odds ratio, 2.2 [95% CI, 1.5-3.2], P<0.0001, respectively). Subjects in the high-to-moderate group had an increased risk of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.82 [95% CI, 1-3.2]; P=0.04). No significant association was found between trajectory group and hemorrhagic transformation. CONCLUSIONS Patients with acute ischemic stroke demonstrate distinct SBP trajectories during the first 72 hours after EVT that have differing associations with functional outcome. These findings may help identify potential candidates for future blood pressure modulation trials.
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Affiliation(s)
- Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Sreeja Kodali
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Can Meng
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT
| | - Fangyong Li
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT
| | - Cindy Khanh Nguyen
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Krithika U. Peshwe
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Sumita Strander
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Andrew Silverman
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Alexandra Kimmel
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Anson Wang
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Mohammad Anadani
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Eyad Almallouhi
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Alejandro M. Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
| | - James A. Giles
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Salah G. Keyrouz
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Cynthia Zevallos
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Ilko L. Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Marios-Nikos Psychogios
- Department of Diagnostic and Interventional Neuroradiology, University Clinic Basel, Switzerland
| | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Sébastien Richard
- Department of Neurology, University Hospital of Nancy, Nancy, France,,Centre d’Investigation Clinique Plurithématique, INSERM U1116, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Benjamin Gory
- Department of Neuroradiology, University Hospital of Nancy, Nancy, France,,IADI, INSERM U1254, University of Lorraine, Nancy, France
| | | | - Patrick A. Brown
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kyle M. Fargen
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Eva A. Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Hiba Fakhri
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Ka-Ho Wong
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT
| | - Adam de Havenon
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Peter Kan
- Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT
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Bath PM, Song L, Silva GS, Mistry E, Petersen N, Tsivgoulis G, Mazighi M, Bang OY, Sandset EC. Blood Pressure Management for Ischemic Stroke in the First 24 Hours. Stroke 2022; 53:1074-1084. [PMID: 35291822 DOI: 10.1161/strokeaha.121.036143] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High blood pressure (BP) is common after ischemic stroke and associated with a poor functional outcome and increased mortality. The conundrum then arises on whether to lower BP to improve outcome or whether this will worsen cerebral perfusion due to aberrant cerebral autoregulation. A number of large trials of BP lowering have failed to change outcome whether treatment was started prehospital in the community or hospital. Hence, nuances on how to manage high BP are likely, including whether different interventions are needed for different causes, the type and timing of the drug, how quickly BP is lowered, and the collateral effects of the drug, including on cerebral perfusion and platelets. Specific scenarios are also important, including when to lower BP before, during, and after intravenous thrombolysis and endovascular therapy/thrombectomy, when it may be necessary to raise BP, and when antihypertensive drugs taken before stroke should be restarted. This narrative review addresses these and other questions. Although further large trials are ongoing, it is increasingly likely that there is no simple answer. Different subgroups of patients may need to have their BP lowered (eg, before or after thrombolysis), left alone, or elevated.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.).,Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (P.M.B.)
| | - Lili Song
- The George Institute China at Peking University Health Science Center, Beijing (L.S.).,Faculty of Medicine, George Institute for Global Health, University of New South Wales, Sydney, Australia (L.S.)
| | - Gisele S Silva
- Neurology, Federal University of São Paulo (UNIFESP) and Hospital Israelita Albert Einstein, Brazil (G.S.S.)
| | - Eva Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (E.M.)
| | - Nils Petersen
- Department of Neurology, Divisions of Vascular Neurology and Neurocritical Care, Yale School of Medicine, New Haven (N.P.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (G.T.)
| | - Mikael Mazighi
- Department of Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris, INSERM 1148, FHU Neurovasc, France (M.M.)
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.)
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Norway (E.C.S.).,The Norwegian Air Ambulance Foundation, Oslo (E.C.S.)
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25
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Abstract
PURPOSE OF REVIEW Blood pressure management in acute stroke has long been a matter of debate. Epidemiological data show that high blood pressure is associated with death, disability and early stroke recurrence, whereas the pathophysiological rationale for ensuring elevated blood pressure in order maintain adequate cerebral perfusion remains a pertinent argument, especially in ischaemic stroke. RECENT FINDINGS The European Stroke Organisation Guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage provide recommendations for the appropriate management of blood pressure in various clinical acute stroke settings. SUMMARY In this narrative review, we provide specific updates on blood pressure management in ICH, blood pressure management in the setting of reperfusion therapies for ischaemic stroke, and the evidence for the use of induced hypertension in patients with acute ischaemic stroke in the light of the recent guidelines.
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Affiliation(s)
- Rajiv Advani
- Stroke Unit, Department of Neurology, Oslo University Hospital
- The Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital
- The Norwegian Air Ambulance Foundation, Oslo
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26
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Kircher CE, Adeoye O. Prehospital and Emergency Department Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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27
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Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Matusevicius M, Cooray C, Holmin S, Bottai M, Ahmed N. Association between systolic blood pressure course and outcomes after stroke thrombectomy. BMJ Neurol Open 2021; 3:e000183. [PMID: 34870205 PMCID: PMC8603273 DOI: 10.1136/bmjno-2021-000183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022] Open
Abstract
Background Systolic blood pressure (SBP) after endovascular thrombectomy (EVT) for large artery occlusive stroke is dynamic, requiring adaptable early prediction tools for improving outcomes. We investigated if post-EVT SBP course was associated with outcomes. Methods EVT-treated patients who had a stroke at Karolinska University Hospital, Stockholm, Sweden, were included in the study during 12 February 2018–11 February 2020. SBP was recorded during the first 24 hours after EVT. Primary outcome was functional independence defined by a Modified Rankin Scale score of 0–2 at 3 months. Secondary outcomes were death by 3 months, symptomatic intracranial haemorrhage and any intracranial haemorrhage. Patients with favourable outcomes were used as a reference SBP course in mixed linear effects models and compared with SBP courses of patients with unfavourable outcomes using the empirical best linear unbiased predictor, measuring deviations from the reference SBP course using the random effects. We tested model predictive stability for SBP measurements of only 18, 12 or 6 hours after EVT. Results 374 patients were registered, with mean age 71, median NIHSS score of 15, and 53.2% men. Deviating from a linear SBP course starting at 130 mm Hg and decreasing to 123 mm Hg at 24 hours after EVT was associated with lower chances of functional independence (adjusted OR 0.53, 95% CI 0.29 to 0.88, for reaching either 99 or 147 mm Hg at 24 hours after EVT). All SBP course models for the remaining outcomes did not show statistical significance. Functional independence models showed stable predictive values for all time periods. Conclusion Deviating from a linear SBP course was associated with lower chances of 3-month functional independence.
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Affiliation(s)
- Marius Matusevicius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
| | - Charith Cooray
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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29
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Maïer B, Gory B, Lapergue B, Sibon I, Escalard S, Kyheng M, Labreuche J, de Havenon A, Petersen N, Anadani M, Gayat E, Boursin P, Ben Maacha M, Desilles JP, Blanc R, Piotin M, Halimi JM, Mazighi M. Effect of blood pressure variability in the randomized controlled BP TARGET trial. Eur J Neurol 2021; 29:771-781. [PMID: 34821437 DOI: 10.1111/ene.15194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE The Blood Pressure Target in Acute Ischemic Stroke to Reduce Hemorrhage After Endovascular Therapy (BP TARGET) trial evaluated whether an intensive systolic blood pressure (SBP) target resulted in reduced rates of intracranial hemorrhage (ICH) after successful endovascular therapy (EVT) but did not assess the effect of blood pressure variability (BPV) on functional outcomes and ICH occurrence. We sought to evaluate this question in the BP TARGET trial. METHODS We performed a post hoc analysis of the BP TARGET trial and included patients with at least 50% of blood pressure (BP) recordings during the first 24 h after EVT. BPV parameters were SBP and diastolic BP (DBP) coefficient of variation (CV), standard deviation (SD), maximum-minimum (max-min), successive variation (SV), and time rate. The primary outcome was favorable functional outcome (3-month modified Rankin Scale between 0 and 2); the secondary outcome was the rate of ICH at 24 h. RESULTS We included 290 patients (mean number of BP measures = 30.4, SD = 8.0). BPV parameters (SBPSD , SBPmax-min , SBPCV ) were higher in the intensive SBP target group. Only DBP BPV parameters were associated with worse functional outcomes in the unadjusted model (DBPSD , DBPmax-min , DBPCV , and DBPSV ), but not after adjustment. Higher SBPmax-min was associated with worse functional outcomes in Thrombolysis in Cerebral Infarction 2B patients (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.38-1.02), but not in patients with complete reperfusion (OR = 1.27, 95% CI = 0.80-2.02, p for heterogeneity (phet =0.037). None of the BPV parameters was associated with ICH, regardless of the randomization group or the reperfusion grade. CONCLUSIONS BPV was significantly higher in the intensive SBP target group but was not associated with functional outcome or ICH.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,University of Paris, Paris, France.,FHU NeuroVasc, Paris, France.,EA4245-Transplantation, Immunology, and Inflammation, University of Tours, Tours, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, University of Lorraine, Nancy, France.,IADI, INSERM U1254, University of Lorraine, Nancy, France
| | - Bertrand Lapergue
- Division of Neurology, Department of Neurology, Stroke Center, Foch Hospital, Versailles Saint-Quentin-en-Yvelines University, Suresnes, France
| | - Igor Sibon
- Stroke Unit, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Simon Escalard
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France
| | - Maeva Kyheng
- University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France
| | - Julien Labreuche
- University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France
| | - Adam de Havenon
- Neurology Department, University of Utah, Salt Lake City, Utah, USA
| | - Nils Petersen
- Neurocritical Care and Emergency Neurology, Yale School of Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Mohammad Anadani
- Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Etienne Gayat
- University of Paris, Paris, France.,Department of Anesthesiology, Critical Care and Burn Center, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, Paris, France.,INSERM UMR-S 942, Cardiovascular Makers in Stress Conditions, Paris, France
| | - Perrine Boursin
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France
| | - Malek Ben Maacha
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,University of Paris, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Raphael Blanc
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Jean-Michel Halimi
- EA4245-Transplantation, Immunology, and Inflammation, University of Tours, Tours, France.,Nephrology Department, Tours Hospital, Tours, France.,University of Tours, Tours, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Adolphe de Rothschild Hospital Foundation, Paris, France.,University of Paris, Paris, France.,FHU NeuroVasc, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
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30
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Simonsen CZ, Bösel J, Rasmussen M. Periprocedural Management During Stroke Thrombectomy. Neurology 2021; 97:S105-S114. [PMID: 34785609 DOI: 10.1212/wnl.0000000000012798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 02/24/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF REVIEW Endovascular therapy (EVT) for acute ischemic stroke caused by large vessel occlusion is a powerful and evidence-based tool to achieve reperfusion and results in improved neurologic outcome. Focus has now shifted toward optimizing the procedure. We reviewed the relevant current literature on periprocedural stroke care such as pretreatment with IV tissue plasminogen activator (tPA), choice of anesthesia, ventilation strategy, and blood pressure management. RECENT FINDINGS IV tPA should not be withheld in a patients with stroke eligible for EVT. A meta-analysis of randomized trials on general anesthesia (GA) vs procedural sedation has shown better neurologic outcomes with protocol-based GA in centers with dedicated neuroanesthesia teams. There are no data from randomized trials on blood pressure control, but according to available evidence, systolic blood pressure should probably be held at >140 mm Hg during the procedure and <160 mm Hg after reperfusion. In ventilated patients, extreme deviations from normoxemia and normocapnia should be avoided. SUMMARY Periprocedural care influences the outcome after EVT for large vessel ischemic stroke. More evidence from prospective ongoing and future studies is urgently needed to identify its optimization.
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Affiliation(s)
- Claus Z Simonsen
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany.
| | - Julian Bösel
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany
| | - Mads Rasmussen
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany
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31
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Huang X, Xu J, Yang K, Xu Y, Yuan L, Cai Q, Xu X, Yang Q, Zhou Z, Zhu S, Liu X. Blood Pressure After Endovascular Thrombectomy and Malignant Cerebral Edema in Large Vessel Occlusion Stroke. Front Neurol 2021; 12:707275. [PMID: 34744962 PMCID: PMC8564062 DOI: 10.3389/fneur.2021.707275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Elevated blood pressure (BP) can cause blood–brain barrier disruption and facilitates brain edema formation. We aimed to investigate the association of BP level after thrombectomy with the development of malignant cerebral edema (MCE) in patients treated with endovascular thrombectomy (EVT). Methods: Consecutive patients who underwent EVT for an anterior circulation ischemic stroke were enrolled from three comprehensive stroke centers. BP was measured hourly during the first 24 h after thrombectomy. MCE was defined as swelling causing a midline shift on the follow-up imaging within 5 days after EVT. Associations of various BP parameters, including mean BP, maximum BP (BPmax), and BP variability (BPV), with the development of MCE were analyzed. Results: Of the 498 patients (mean age 66.9 ± 11.7 years, male 58.2%), 97 (19.5%) patients developed MCE. Elevated mean systolic BP (SBP) (OR, 1.035; 95% CI, 1.006–1.065; P = 0.017) was associated with a higher likelihood of MCE. The best SBPmax threshold that predicted the development of MCE was 165 mmHg. Additionally, increases in BPV, as evaluated by SBP standard deviation (OR, 1.061; 95% CI, 1.003–1.123; P = 0.039), were associated with higher likelihood of MCE. Interpretation: Elevated mean SBP and BPV were associated with a higher likelihood of MCE. Having a SBPmax > 165 mm Hg was the best threshold to discriminate the development of MCE. These results suggest that continuous BP monitoring after EVT could be used as a non-invasive predictor for clinical deterioration due to MCE. Randomized clinical studies are warranted to address BP goal after thrombectomy.
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Affiliation(s)
- Xianjun Huang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Junfeng Xu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Ke Yang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Youqing Xu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Lili Yuan
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Qiankun Cai
- Department of Neurology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiangjun Xu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Qian Yang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Zhiming Zhou
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Shuanggen Zhu
- Department of Neurology, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, China.,Department of Neurology, People's Hospital of Longhua, Shenzhen, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Division of Life Sciences and Medicine, Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
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32
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Couture M, Marnat G, Griffier R, Gariel F, Olindo S, Renou P, Sagnier S, Berge J, Tourdias T, Sibon I. Antiplatelet therapy increases symptomatic ICH risk after thrombolysis and thrombectomy. Acta Neurol Scand 2021; 144:500-508. [PMID: 34042170 DOI: 10.1111/ane.13468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/29/2021] [Accepted: 04/21/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE The influence of chronic treatment by antiplatelet drug (APD) at stroke onset on the outcomes of patients with acute ischemic stroke (AIS) treated with combined intravenous thrombolysis (IVT) and endovascular therapy (EVT) is unclear. We investigated whether prior APD use influences the risk of symptomatic intracranial hemorrhage (sICH) and functional outcome in AIS patients treated with combined reperfusion therapy. METHODS A single-center retrospective analysis of AIS patients with proximal intracranial occlusion who underwent IVT and EVT between January 2015 and May 2017. The main outcomes were the incidence of sICH using the Heidelberg Bleeding Classification and patients' functional status at 90 days, as defined by the modified Rankin scale (mRS). Outcomes were evaluated according to daily exposure to APD, and associations were assessed using multivariate logistic regression analysis. RESULTS This study included 204 patients: 71 (34.8%) were taking APD before AIS. Patients with chronic treatment by APD at stroke onset had a higher rate of sICH (26.7% vs. 3.7%; p< .001) and worse functional outcome (mRS >2) at 90 days (69% vs. 36.8%; p < .001). Prior APD use was associated with an increased likelihood of sICH (OR 9.8; 95%CI [3.6-31.3], p < .05) and of functional dependence at 90 days (OR 5.72; 95%CI [2.09-1.72], p < .001), independent of confounders on multivariate analysis. CONCLUSIONS Chronic treatment by APD at stroke onset in AIS patients with proximal intracranial occlusion treated using IVT and EVT increases the risk of sICH and worsens the functional prognosis. Further investigation to refine acute revascularization strategies in this population might be required.
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Affiliation(s)
- Marie Couture
- CHU de Bordeaux Unité Neuro‐vasculaire Bordeaux France
| | - Gaultier Marnat
- CHU de Bordeaux Neuroimagerie diagnostique et thérapeutique Bordeaux France
| | - Romain Griffier
- CHU de Bordeaux Pôle de Santé Publique Service d’information médicale Bordeaux France
| | - Florent Gariel
- CHU de Bordeaux Neuroimagerie diagnostique et thérapeutique Bordeaux France
| | | | - Pauline Renou
- CHU de Bordeaux Unité Neuro‐vasculaire Bordeaux France
| | - Sharmila Sagnier
- CHU de Bordeaux Unité Neuro‐vasculaire Bordeaux France
- UMR 5287 CNRS Université de Bordeaux EPHE PSL Research University Bordeaux France
| | - Jerome Berge
- CHU de Bordeaux Neuroimagerie diagnostique et thérapeutique Bordeaux France
| | - Thomas Tourdias
- CHU de Bordeaux Neuroimagerie diagnostique et thérapeutique Bordeaux France
- INSERM‐U1215 Neurocentre Magendie Bordeaux France
| | - Igor Sibon
- CHU de Bordeaux Unité Neuro‐vasculaire Bordeaux France
- UMR 5287 CNRS Université de Bordeaux EPHE PSL Research University Bordeaux France
- Université de Bordeaux Bordeaux France
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33
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Tao C, Xu P, Yao Y, Zhu Y, Li R, Li J, Luo W, Hu W. A Prospective Study to Investigate Controlling Blood Pressure Under Transcranial Doppler After Endovascular Treatment in Patients With Occlusion of Anterior Circulation. Front Neurol 2021; 12:735758. [PMID: 34659095 PMCID: PMC8511455 DOI: 10.3389/fneur.2021.735758] [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: 07/03/2021] [Accepted: 08/26/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: The objective of this study was to evaluate the effect of blood pressure (BP) management with transcranial Doppler (TCD) guidance in patients with large-vessel occlusion in the anterior circulation after endovascular thrombectomy (EVT) on the long-term prognosis. Methods: This was a prospective study; 232 patients were nonrandomized assigned to TCD-guided BP management (TBM) group or non-TCD-guided BP management (NBM) group. In the TBM group, BP was controlled according to TCD showing cerebral blood flow fluctuation. In the NBM group, BP was controlled according to the guidelines. The primary endpoint was a modified Rankin scale (mRS) score of 2 or lower at 90 days. The safety outcomes were the rates of symptomatic or any intracerebral hemorrhage (ICH) and mortality at 90 days. Results: One hundred sixty-three patients were assigned to the TBM group, and 69 were assigned to the NBM group. In the propensity score-matched cohort (65 matches in both groups), there was significant difference in the proportion of participants with mRS 0–2 at 90 days according to BP management (adjusted odds ratio 3.34, 95% CI 1.36 to 8.22). There was no difference in the rates of symptomatic or any ICH and mortality between two groups. In inverse probability-weighted regression adjustment analysis, mortality decreased significantly in the TBM group than in the NBM group (adjusted odds ratio 0.86, 95% CI 0.76–0.99, p = 0.03). Conclusion: In patients with acute ischemic stroke from large-vessel occlusion in the anterior circulation, BP management under TCD was superior to NBM in improving the clinical outcomes at 90 days. Clinical Trial Registration: (URL: https://www.chictr.org.cn/showproj.aspx?proj=55484; Identifier: ChiCTR2000034443.
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Affiliation(s)
- Chunrong Tao
- Division of Life Sciences and Medicine, Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Pengfei Xu
- Division of Life Sciences and Medicine, Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Yang Yao
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Yajuan Zhu
- Division of Life Sciences and Medicine, Department of Ultrasound, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Rui Li
- Division of Life Sciences and Medicine, Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Jie Li
- Division of Life Sciences and Medicine, Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Wenwu Luo
- Department of pathology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wei Hu
- Division of Life Sciences and Medicine, Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
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Abstract
ABSTRACT While acute blood pressure elevations are commonly seen in the ED, not all require emergency treatment. True hypertensive emergencies are characterized by a rapid elevation in blood pressure to a level above 180/120 mmHg and are associated with acute target organ damage, which requires immediate hospitalization for close hemodynamic monitoring and IV pharmacotherapy. Recognizing the clinical signs and symptoms of hypertensive emergency, which may vary widely depending on the target organ involved, is critical. High blood pressure levels that produce no signs or symptoms of target organ damage may be treated without hospitalization through an increase in or reestablishment of previously prescribed oral antihypertensive medication. However, all patients presenting with blood pressure this high should undergo evaluation to confirm or rule out impending target organ damage, which differentiates hypertensive emergency from other hypertensive crises and is vital in facilitating appropriate emergency treatment. Drug therapy for hypertensive emergency is influenced by end-organ involvement, pharmacokinetics, potential adverse drug effects, and patient comorbidities. Frequent nursing intervention and close monitoring are crucial to recuperation. Here, the authors define the spectrum of uncontrolled hypertension; discuss the importance of distinguishing hypertensive emergencies from hypertensive urgencies; and describe the pathophysiology, clinical manifestations, and management of hypertensive emergencies.
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Affiliation(s)
- Essie P Mathews
- Kartavya Sharma is an assistant professor in the Departments of Neurology and Neurological Surgery at the University of Texas Southwestern Medical Center, Dallas, where Essie P. Mathews is an advanced practice RN in the Department of Neurology and Faith Newton is an adult-gerontology acute care NP in the Department of Neurology. Contact author: Kartavya Sharma, . The authors and planners have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the authors is available at www.ajnonline.com
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35
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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: 6] [Impact Index Per Article: 2.0] [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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36
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Samuels N, van de Graaf RA, van den Berg CAL, Uniken Venema SM, Bala K, van Doormaal PJ, van der Steen W, Witvoet E, Boiten J, den Hertog H, Schonewille WJ, Hofmeijer J, Schreuder F, Schreuder TAHCML, van der Worp HB, Roos YBWEM, Majoie CBLM, Burke JF, van Es ACGM, van der Lugt A, Roozenbeek B, Lingsma HF, Dippel DWJ. Blood Pressure in the First 6 Hours Following Endovascular Treatment for Ischemic Stroke Is Associated With Outcome. Stroke 2021; 52:3514-3522. [PMID: 34538090 PMCID: PMC8547588 DOI: 10.1161/strokeaha.120.033657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Optimal blood pressure (BP) management in the acute phase of ischemic stroke remains an unresolved issue. It is uncertain whether guidelines for BP management during and after intravenous alteplase can be extrapolated to endovascular treatment (EVT) for stroke due to large artery occlusion in the anterior circulation. We evaluated the associations between systolic BP (SBP) in the first 6 hours following EVT and functional outcome as well as symptomatic intracranial hemorrhage. Methods: Patients of 8 MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry centers, with available data on SBP in the 6 hours following EVT, were analyzed. We evaluated maximum, minimum, and mean SBP. Study outcomes were functional outcome (modified Rankin Scale) at 90 days and symptomatic intracranial hemorrhage. We used multivariable ordinal and binary regression analysis to adjust for important prognostic factors and studied possible effect modification by successful reperfusion. Results: Post-EVT SBP data were available for 1161/1796 patients. Higher maximum SBP (per 10 mm Hg increments) was associated with worse functional outcome (adjusted common odds ratio, 0.93 [95% CI, 0.88–0.98]) and a higher rate of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.17 [95% CI, 1.02–1.36]). The association between minimum SBP and functional outcome was nonlinear with an inflection point at 124 mm Hg. Minimum SBP lower and higher than the inflection point were associated with worse functional outcomes (adjusted common odds ratio, 0.85 per 10 mm Hg decrements [95% CI, 0.76–0.95] and adjusted common odds ratio, 0.81 per 10 mm Hg increments [95% CI, 0.71–0.92]). No association between mean SBP and functional outcome was observed. Successful reperfusion did not modify the relation of SBP with any of the outcomes. Conclusions: Maximum SBP in the first 6 hours following EVT is positively associated with worse functional outcome and an increased risk of symptomatic intracranial hemorrhage. Both lower and higher minimum SBP are associated with worse outcomes. A randomized trial to evaluate whether modifying post-intervention SBP results in better outcomes after EVT for ischemic stroke seems justified.
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Affiliation(s)
- Noor Samuels
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Public Health (N.S., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Carlijn A L van den Berg
- Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands (S.M.U.V., H.B.v.d.W.)
| | - Kujtesa Bala
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wouter van der Steen
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Elbert Witvoet
- Department of Neurology, Haga Hospital, Den Haag, the Netherlands (E.W.)
| | - Jelis Boiten
- Department of Neurology, Haaglanden Medical Center, Den Haag, the Netherlands (J.B.)
| | - Heleen den Hertog
- Department of Neurology, Isala Hospital, Zwolle, the Netherlands (H.d.H.)
| | - Wouter J Schonewille
- Department of Neurology, Sint Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.)
| | | | - Floris Schreuder
- Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherlands (F.S.)
| | | | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands (S.M.U.V., H.B.v.d.W.)
| | - Yvo B W E M Roos
- Department of Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Centers, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine (C.B.L.M.M.), Amsterdam University Medical Centers, the Netherlands
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor (J.F.B.)
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine, Leiden University Medical Center, the Netherlands (A.C.G.M.v.E.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health (N.S., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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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: 17] [Impact Index Per Article: 5.7] [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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38
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Sandset EC, Anderson CS, Bath PM, Christensen H, Fischer U, Gąsecki D, Lal A, Manning LS, Sacco S, Steiner T, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J 2021; 6:XLVIII-LXXXIX. [PMID: 34780578 PMCID: PMC8370078 DOI: 10.1177/23969873211012133] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/05/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke.The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
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Affiliation(s)
- Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- The George Institute China at Peking University Health Science Center, Beijing, PR China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital & University of Copenhagen, Copenhagen, Denmark
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dariusz Gąsecki
- Department of Adult Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - Avtar Lal
- Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Lisa S Manning
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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39
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Xu C, Lin G, Zhang Z, Jin T, Li N, Mao H, Ye S, Yang Z, Geng Y, Shi Z. Prolonged Duration of Blood Pressure Drops During General Anesthesia Is Associated With Worse Outcomes After Mechanical Thrombectomy. Front Neurol 2021; 12:640841. [PMID: 33854476 PMCID: PMC8039315 DOI: 10.3389/fneur.2021.640841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 02/18/2021] [Indexed: 11/22/2022] Open
Abstract
Background and Purpose: Optimal periprocedural management of blood pressure during mechanical thrombectomy (MT) remains controversial. This study aimed to investigate the relationship between the duration of blood pressure drops during general anesthesia and the outcomes in large vessel occlusion (LVO) patients treated with MT. Methods: We retrospectively reviewed our prospectively collected data for LVO patients treated with MT between January 2018 and July 2020. Intraprocedural mean arterial pressure (MAP) was recorded every 5 min throughout the procedure. Baseline MAP minus each MAP value recorded during general anesthesia was defined ΔMAP. Cumulated time (in min) and longest continuous episode (in min) with ΔMAP more than 10, 15, 20, 25, and 30 mmHg were calculated, respectively. Poor outcome was defined as 90-day modified Rankin score (mRS) 3–6. Associations between cumulated time of different ΔMAP thresholds and poor outcome were determined using binary logistic regression models. Results: A total of 131 patients were finally included in the study. After controlling for age, atrial fibrillation, baseline NIHSS, baseline ASPECTS, procedure duration of MT, and times of retrieval attempts, the results indicated that cumulated time of MAP drop more than 10 mmHg (OR 1.013; 95% CI 1.004–1.023; P = 0.007) and 15 mmHg (OR 1.011; 95% CI 1.002–1.020; P = 0.017) were independently associated with poor outcomes. Conclusion: Prolonged episodes of intraprocedural MAP lowering were more likely to have poor outcomes in LVO patients following MT with general anesthesia, which might be helpful in guiding intraprocedural hemodynamic management of patients under general anesthesia.
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Affiliation(s)
- Chao Xu
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Gaoping Lin
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Zheyu Zhang
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, China
| | - Tianyu Jin
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ning Li
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, China
| | - Hui Mao
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Sasa Ye
- Department of Radiology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Zongming Yang
- Department of Epidemiology and Biostatistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Zongjie Shi
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
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40
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Rodgers ML, Fox E, Abdelhak T, Franker LM, Johnson BJ, Kirchner-Sullivan C, Livesay SL, Marden FA. Care of the Patient With Acute Ischemic Stroke (Endovascular/Intensive Care Unit-Postinterventional Therapy): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association. Stroke 2021; 52:e198-e210. [PMID: 33691467 DOI: 10.1161/str.0000000000000358] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Ischemic stroke remains the fifth leading cause of death in the United States. Nurses play a pivotal role in the care of patients throughout the continuum. With the advances in stroke care, including mechanical thrombectomy, the American Heart Association/American Stroke Association charged the writing panel to complement the 2009 clinical practice guideline, "Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient," with current evidence-based nursing care. This update is 1 of a 3-part series focusing on emergency medical services/emergency care, endovascular/intensive care unit care, and postacute care. The aim of this scientific statement is to review and present current evidence, complications, best practices, and clinical practice strategies to provide current comprehensive scientific information for nursing care in the neuroendovascular area and intensive care unit in conjunction with medical treatments, including intravenous thrombolysis and mechanical thrombectomy.
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41
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An J, Tang Y, Cao X, Yuan H, Wei M, Yuan X, Zhang A, Li Y, Saguner A, Li G, Luo G. Systemic arterial blood pressure and intracerebral hemorrhage after mechanical thrombectomy in anterior cerebral circulation. J Investig Med 2021; 69:1008-1014. [PMID: 33653704 PMCID: PMC8223637 DOI: 10.1136/jim-2020-001554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 12/11/2022]
Abstract
The relationship between systemic arterial blood pressure (BP) and intracerebral hemorrhage (ICH) after mechanical thrombectomy (MT) of the cerebral artery remains unclear. This study aimed to determine the effect of BP variables on ICH after MT in patients with acute occlusions of the anterior cerebral circulation. Patients undergoing MT due to acute occlusions of the anterior cerebral circulation were enrolled in this single-center study. Non-invasive BP data following MT were obtained within the first 24 hours, including mean, maximum, minimum, difference between maximum and minimum, SD and coefficient of variation for systolic BP (SBP) and diastolic BP (DBP) and mean arterial pressure. ICH was defined and classified according to the European Cooperative Acute Stroke Study-II. In 164 enrolled patients (median age 65 (IQR 56–75) years; 31.7% female), higher maximum (89.5 mm Hg vs 98.5 mm Hg, p=0.001) and SD (9.8 mm Hg vs 10.9 mm Hg, p=0.038) of DBP were associated with higher risk of ICH. The optimal cut-off values associated with ICH for maximum SBP were 155 mm Hg and for maximum DBP 92.5 mm Hg, respectively. Higher BP within 24 hours after MT in acute occlusions of the anterior cerebral circulation is associated with a greater risk of ICH. More studies are needed to further determine optimal BP goals in the acute phase after MT.
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Affiliation(s)
- Jiaqi An
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yonglan Tang
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiangqi Cao
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Huijie Yuan
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Meng Wei
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xingyun Yuan
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Aifeng Zhang
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yongxin Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ardan Saguner
- Department of Cardiology, University Heart Center Zürich, Zürich, Switzerland
| | - Guoliang Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guogang Luo
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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42
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Liu D, Nie X, Pan Y, Yan H, Pu Y, Wei Y, Cai Y, Ding Y, Lu Q, Zhang Z, Gu W, Hou X, Yang Z, Wen M, Wang P, Ma G, Ma N, Miao Z, Leng X, Yan B, Davis SM, Wang Y, Liu L. Adverse Outcomes Associated With Higher Mean Blood Pressure and Greater Blood Pressure Variability Immediately After Successful Embolectomy in Those With Acute Ischemic Stroke, and the Influence of Pretreatment Collateral Circulation Status. J Am Heart Assoc 2021; 10:e019350. [PMID: 33634704 PMCID: PMC8174261 DOI: 10.1161/jaha.120.019350] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background To investigate whether collateral status could modify the associations between post‐thrombectomy blood pressure (BP) measures and outcomes. Methods and Results Patients with anterior‐circulation large‐vessel‐occlusion successfully recanalized in a multicenter endovascular thrombectomy registry were enrolled. Pretreatment collateral status was graded and dichotomized (good/poor) in angiography. Maximum, minimum, and mean systolic BP (SBP) and BP variability (assessed by the SD, coefficient of variation) during the initial 24 hours after endovascular thrombectomy were obtained. The primary outcome was unfavorable 90‐day outcome (modified Rankin Scale score 3–6). Secondary outcomes included symptomatic intracranial hemorrhage and 90‐day mortality. Adjusted odds ratios (aOR) of BP parameters over the outcomes were obtained in all patients and in patients with good/poor collaterals. Among 596 patients (mean age 66 years; 59.9% males), 302 (50.7%) patients had unfavorable 90‐day outcome. In multivariable analyses, higher mean SBP (aOR, 1.59 per 10 mm Hg increment; 95% CI, 1.26–2.02; P<0.001), mean SBP >140 mm Hg (versus ≤120 mm Hg; aOR, 4.27; 95% CI, 1.66–10.97; P=0.002), and higher SBP SD (aOR, 1.08 per 1‐SD increment; 95% CI, 1.01–1.16; P=0.02) were respectively associated with unfavorable 90‐day outcome in patients with poor collateral but not in those with good collateral. A marginal interaction between SBP coefficient of variation tertiles and collaterals on 90‐day functional outcome (P for interaction, 0.09) was observed. A significant interaction between SBP coefficient of variation tertiles and collaterals on 90‐day mortality (P for interaction, 0.03) was observed. Conclusions Higher postprocedural BP is associated with 90‐day unfavorable outcomes after successful endovascular thrombectomy in patients with poor collateral. Registration URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1900022154.
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Affiliation(s)
- Dacheng Liu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Ximing Nie
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuesong Pan
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Hongyi Yan
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuehua Pu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yufei Wei
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yuan Cai
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Yarong Ding
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Qixuan Lu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Zhe Zhang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Weibin Gu
- Department of Radiology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Xinyi Hou
- Department of Radiology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Zhonghua Yang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Miao Wen
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Penglian Wang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Gaoting Ma
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Ning Ma
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Zhongrong Miao
- Department of Interventional Neurology Beijing Tiantan HospitalCapital Medical University Beijing China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Prince of Wales Hospital Chinese University of Hong Kong Hong Kong SAR China
| | - Bernard Yan
- Department of Medicine and Neurology Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of Melbourne Parkville Victoria Australia
| | - Stephen M Davis
- Department of Medicine and Neurology Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of Melbourne Parkville Victoria Australia
| | - Yongjun Wang
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
| | - Liping Liu
- Department of Neurology Beijing Tiantan HospitalCapital Medical University Beijing China.,China National Clinical Research Center for Neurological Diseases Beijing China
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43
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Intensive Care Admission and Management of Patients With Acute Ischemic Stroke: A Cross-sectional Survey of the European Society of Intensive Care Medicine. J Neurosurg Anesthesiol 2021; 34:313-320. [PMID: 33587531 DOI: 10.1097/ana.0000000000000761] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND No specific recommendations are available regarding the intensive care management of critically ill acute ischemic stroke (AIS) patients, and questions remain regarding optimal ventilatory, hemodynamic, and general intensive care unit (ICU) therapeutic targets in this population. We performed an international survey to investigate ICU admission criteria and management of AIS patients. METHODS An electronic questionnaire including 25 items divided into 3 sections was available on the European Society of Intensive Care Medicine Web site between November 1, 2019 and March 30, 2020 and advertised through the neurointensive care (NIC) section newsletter. This survey was emailed directly to the NIC members and was endorsed by the European Society of Intensive Care Medicine. RESULTS There were 214 respondents from 198 centers, with response rate of 16.5% of total membership (214/1296). In most centers (67%), the number of AIS patients admitted to respondents' hospitals in 2019 was between 100 and 300, and, among them, fewer than 50 required ICU admission per hospital. The most widely accepted indication for ICU admission criteria was a requirement for intubation and mechanical ventilation. A standard protocol for arterial blood pressure (ABP) management was utilized by 88 (58%) of the respondents. For patients eligible for intravenous thrombolysis, the most common ABP target was <185/110 mm Hg (n=77 [51%]), whereas for patients undergoing mechanical thrombectomy it was ≤160/90 mm Hg (n=79 [54%]). The preferred drug for reducing ABP was labetalol (n=84 [55.6%]). Other frequently used therapeutic targets included: blood glucose 140 to 180 mg/dL (n=65 [43%]) maintained with intravenous insulin infusion in most institutions (n=110 [72.4%]); enteral feeding initiated within 2 to 3 days from stroke onset (n=142 [93.4%]); oxygen saturation (SpO2) >95% (n=80 [53%]), and tidal volume 6 to 8 mL/kg of predicted body weight (n=135 [89%]). CONCLUSIONS The ICU management of AIS, including therapeutic targets and clinical practice strategies, importantly varies between centers. Our findings may be helpful to define future studies and create a research agenda regarding the ICU therapeutic targets for AIS patients.
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Charbonnier G, Bonnet L, Biondi A, Moulin T. Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke. Front Neurol 2021; 11:629920. [PMID: 33633661 PMCID: PMC7900408 DOI: 10.3389/fneur.2020.629920] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022] Open
Abstract
Intracranial hemorrhage is one of the most feared complications following brain infarct. Ischemic tissues have a natural tendency to bleed. Moreover, the first recanalization trials using intravenous thrombolysis have shown an increase in mild to severe intracranial hemorrhage. Symptomatic intracerebral hemorrhage is strongly associated with poor outcomes and is an important factor in recanalization decisions. Stroke physicians have to weigh the potential benefit of recanalization therapies, first, with different risks of intracranial hemorrhage described in randomized controlled trials, and second with numerous risk markers that have been found to be associated with intracranial hemorrhage in retrospective series. These decisions have become quite complex with different intravenous thrombolytics and mechanical thrombectomy. This review aims to outline some elements of the pathophysiological mechanisms and classifications, describe most of the risk factors identified for each reperfusion therapy, and finally suggest future research directions that could help physicians dealing with these complications.
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Affiliation(s)
- Guillaume Charbonnier
- Neurology Department, Besançon University Hospital, Besançon, France.,Interventional Neuroradiology Department, Besançon University Hospital, Besançon, France.,EA 481 Neurosciences laboratory, Franche-Comté University, Besançon, France
| | - Louise Bonnet
- Neurology Department, Besançon University Hospital, Besançon, France
| | - Alessandra Biondi
- Interventional Neuroradiology Department, Besançon University Hospital, Besançon, France.,CIC-1431 Inserm, Besançon, France
| | - Thierry Moulin
- Neurology Department, Besançon University Hospital, Besançon, France.,EA 481 Neurosciences laboratory, Franche-Comté University, Besançon, France.,CIC-1431 Inserm, Besançon, France
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45
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McCarthy DJ, Ayodele M, Luther E, Sheinberg D, Bryant JP, Elwardany O, Kimball J, Starke RM. Prolonged Heightened Blood Pressure Following Mechanical Thrombectomy for Acute Stroke is Associated with Worse Outcomes. Neurocrit Care 2021; 32:198-205. [PMID: 31385182 DOI: 10.1007/s12028-019-00803-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Most data evaluating the relationship of post-mechanical thrombectomy (MT) blood pressure (BP) management and outcomes of patients with large vessel occlusion (LVO) focus on early BP control within the first 24 h. We investigated the correlation of daily BP trends up to the third day following MT with patient outcomes. METHODS We retrospectively reviewed our prospectively maintained database for LVO patients treated with MT from February 2015 to December 2017. Recorded BP values for 72 h post-reperfusion were reviewed. Daily peak systolic and diastolic blood pressures (SBP, DBP) were extracted for each day post-procedure. The association and importance between BP increments of 10 mmHg and mortality, hemorrhage, and functional independence (FI = mRS ≤ 2) was analyzed in a multivariable logistic regression and random forest (RF) analyses modeling. RESULTS A total of 212 thrombectomies were included. An increase in peak 24-h SBP was independently associated with higher likelihood of symptomatic hemorrhage (OR 1.2, p = 0.048) and decreased functional independence (OR 0.85, p = 0.03). Higher day 2 and day 3 peak SBP was strongly correlated with decreased functional independence and higher mortality. Third day SBP < 140 was independently associated with higher likelihood of functional independence (OR 4.3, p = 0.0004). Post-MT patients with and without functional independence demonstrated a similar relative decrease in peak SBP between the first 2 days following thrombectomy (p = 0.26); however, those without functional independence experienced a significant rebound increase in peak SBP on the third day following MT (mean change from day 2 to 3: FI - 3.5 mmHg, non-FI + 3.9 mmHg; p = 0.005). CONCLUSION High daily maximum SBP and a rebound SBP on the third day following MT is independently associated with increased likelihood of functional dependence.
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Affiliation(s)
- David J McCarthy
- Department of Neurosurgery, University of Miami, Miami, USA.
- University of Miami Miller School of Medicine, 1095 N.W. 14th Terrace, 2nd Floor (D4-6), Miami, FL, 33136, USA.
| | | | - Evan Luther
- Department of Neurosurgery, University of Miami, Miami, USA
| | | | | | - Omar Elwardany
- Department of Neurosurgery, University of Miami, Miami, USA
| | - John Kimball
- Department of Neurosurgery, University of Miami, Miami, USA
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Optimal blood pressure levels in different phases of peripheral thrombolysis period in acute ischemic stroke. J Hypertens 2021; 39:1453-1461. [PMID: 33560058 DOI: 10.1097/hjh.0000000000002812] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dramatic changes of blood pressure (BP) were observed in the peripheral thrombolysis period, however, there is no consensus about BP control targets in the different phases. METHODS We retrospectively studied a consecutive sample of 510 patients treated with intravenous thrombolysis and followed-up for 3 months. The peripheral thrombolysis period was divided into these phases: Phase 1 (from onset to thrombolysis), Phase 2 (thrombolysis), Phase 3 (from thrombolysis to 24 h after thrombolysis), and Phase 4 (from 24 h to 7 days after thrombolysis). Patients were divided into quintiles according to mean blood pressure in these phases, respectively. Neurological improvement was evaluated using the modified Rankin Scale score at 3-month after thrombolysis. RESULTS Lower risk of intracerebral hemorrhage within 7 days was found in lower quintiles of SBP (OR = 0.100, 95% CI 0.011-0.887, P = 0.039 in Phase 1 quintile Q1, OR = 0.110, 95% CI 0.012-0.974, P = 0.047 in Phase 2-3 quintile Q1, and OR, 0.175, 95% CI, 0.035-0.872; P = 0.033 in Phase 4 quintile Q2, respectively). Better neurological improvement was found in SBP quintiles: Q2-Q4 (127.3-155.7 mmHg) in Phase 4 (OR = 3.095, 95% CI 1.524-6.286, P = 0.002 for Q2; OR = 2.697, 95% CI 1.354-5.370, P = 0.005 for Q3; and OR = 2.491, 95% CI 1.263-4.913, P = 0.008 for Q4, respectively). Our results also showed higher average real variability of SBP was negatively associated with better neurological outcome in Phase 1 and Phase 2-3. CONCLUSIONS Maintaining SBP levels (≤148 mmHg) from admission to the first 24 h after thrombolysis, then keeping SBP levels (127-138 mmHg) would be beneficial.
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Wu K, Xiong Z, Ding Y. Management of Elevated Blood Pressure After Stroke Thrombectomy for Anterior Circulation. Risk Manag Healthc Policy 2021; 14:405-413. [PMID: 33568958 PMCID: PMC7868952 DOI: 10.2147/rmhp.s285316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/25/2021] [Indexed: 12/11/2022] Open
Abstract
Thrombectomy is superior to intravenous thrombolysis for patients with large vessel occlusion in acute ischemic stroke, but nearly half of the patients still experience poor functional outcomes. Elevated blood pressure (BP) is widely observed in acute ischemic stroke, and BP may be one of the modifiable parameters that can potentially influence the outcomes; however, only observational studies exist to support current guidelines, and the recommended range for BP after thrombectomy is too wide to meet the clinical requirement. Randomized controlled trials are therefore needed to better understand the relationship between BP and outcomes after thrombectomy. In this review, we introduce the current management of BP after thrombectomy and several aspects of postthrombectomy BP management that should be resolved in future clinical trials.
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Affiliation(s)
- Kexin Wu
- Postgraduate School, Dalian Medical University, Dalian, People's Republic of China.,Department of Neurosurgery, Taizhou People's Hospital, Taizhou, People's Republic of China
| | - Zhencheng Xiong
- Institute of Medical Technology, Peking University Health Science Center, Beijing, People's Republic of China.,Peking University Third Hospital, Beijing, People's Republic of China
| | - Yasuo Ding
- Postgraduate School, Dalian Medical University, Dalian, People's Republic of China.,Department of Neurosurgery, Taizhou People's Hospital, Taizhou, People's Republic of China
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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 DOI: 10.1055/s-0040-1722721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [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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Hemodynamics in acute stroke: Cerebral and cardiac complications. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:295-317. [PMID: 33632449 DOI: 10.1016/b978-0-12-819814-8.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hemodynamics is the study of blood flow, where parameters have been defined to quantify blood flow and the relationship with systemic circulatory changes. Understanding these perfusion parameters, the relationship between different blood flow variables and the implications for ischemic injury are outlined in the ensuing discussion. This chapter focuses on the hemodynamic changes that occur in ischemic stroke, and their contribution to ischemic stroke pathophysiology. We discuss the interaction between cardiovascular response and hemodynamic changes in stroke. Studying hemodynamic changes has a key role in stroke prevention, therapeutic implications and prognostic importance in acute ischemic stroke: preexisting hemodynamic and autoregulatory impairments predict the occurrence of stroke. Hemodynamic failure predisposes to the formation of thromboemboli and accelerates infarction due to impairing compensatory mechanisms. In ischemic stroke involving occlusion of a large vessel, persistent collateral circulation leads to preservation of ischemic penumbra and therefore justifying endovascular thrombectomy. Following thrombectomy, impaired autoregulation may lead to reperfusion injury and hemorrhage.
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Defining a Taxonomy of Intracranial Hypertension: Is ICP More Than Just a Number? J Neurosurg Anesthesiol 2020; 32:120-131. [PMID: 31135572 DOI: 10.1097/ana.0000000000000609] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Intracranial pressure (ICP) monitoring and control is a cornerstone of neuroanesthesia and neurocritical care. However, because elevated ICP can be due to multiple pathophysiological processes, its interpretation is not straightforward. We propose a formal taxonomy of intracranial hypertension, which defines ICP elevations into 3 major pathophysiological subsets: increased cerebral blood volume, masses and edema, and hydrocephalus. (1) Increased cerebral blood volume increases ICP and arises secondary to arterial or venous hypervolemia. Arterial hypervolemia is produced by autoregulated or dysregulated vasodilation, both of which are importantly and disparately affected by systemic blood pressure. Dysregulated vasodilation tends to be worsened by arterial hypertension. In contrast, autoregulated vasodilation contributes to intracranial hypertension during decreases in cerebral perfusion pressure that occur within the normal range of cerebral autoregulation. Venous hypervolemia is produced by Starling resistor outflow obstruction, venous occlusion, and very high extracranial venous pressure. Starling resistor outflow obstruction tends to arise when cerebrospinal fluid pressure causes venous compression to thus increase tissue pressure and worsen tissue edema (and ICP elevation), producing a positive feedback ICP cycle. (2) Masses and edema are conditions that increase brain tissue volume and ICP, causing both vascular compression and decrease in cerebral perfusion pressure leading to oligemia. Brain edema is either vasogenic or cytotoxic, each with disparate causes and often linked to cerebral blood flow or blood volume abnormalities. Masses may arise from hematoma or neoplasia. (3) Hydrocephalus can also increase ICP, and is either communicating or noncommunicating. Further research is warranted to ascertain whether ICP therapy should be tailored to these physiological subsets of intracranial hypertension.
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