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Appleton JP, Law ZK, Woodhouse LJ, Al-Shahi Salman R, Beridze M, Christensen H, Dineen RA, Guerrero JJE, England TJ, Karlinski M, Krishnan K, Laska AC, Lyrer P, Ozturk S, Roffe C, Roberts I, Robinson TG, Scutt P, Werring DJ, Bath PM, Sprigg N. Effects of blood pressure and tranexamic acid in spontaneous intracerebral haemorrhage: a secondary analysis of a large randomised controlled trial. BMJ Neurol Open 2023; 5:e000423. [PMID: 37337529 PMCID: PMC10277112 DOI: 10.1136/bmjno-2023-000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/06/2023] [Indexed: 06/21/2023] Open
Abstract
Background Tranexamic acid reduced haematoma expansion and early death, but did not improve functional outcome in the tranexamic acid for hyperacute spontaneous intracerebral haemorrhage-2 (TICH-2) trial. In a predefined subgroup, there was a statistically significant interaction between prerandomisation baseline systolic blood pressure (SBP) and the effect of tranexamic acid on functional outcome (p=0.019). Methods TICH-2 was an international prospective double-blind placebo-controlled randomised trial evaluating intravenous tranexamic acid in patients with acute spontaneous intracerebral haemorrhage (ICH). Prerandomisation baseline SBP was split into predefined ≤170 and >170 mm Hg groups. The primary outcome at day 90 was the modified Rankin Scale (mRS), a measure of dependency, analysed using ordinal logistic regression. Haematoma expansion was defined as an increase in haematoma volume of >33% or >6 mL from baseline to 24 hours. Data are OR or common OR (cOR) with 95% CIs, with significance at p<0.05. Results Of 2325 participants in TICH-2, 1152 had baseline SBP≤170 mm Hg and were older, had larger lobar haematomas and were randomised later than 1173 with baseline SBP>170 mm Hg. Tranexamic acid was associated with a favourable shift in mRS at day 90 in those with baseline SBP≤170 mm Hg (cOR 0.73, 95% CI 0.59 to 0.91, p=0.005), but not in those with baseline SBP>170 mm Hg (cOR 1.05, 95% CI 0.85 to 1.30, p=0.63). In those with baseline SBP≤170 mm Hg, tranexamic acid reduced haematoma expansion (OR 0.62, 95% CI 0.47 to 0.82, p=0.001), but not in those with baseline SBP>170 mm Hg (OR 1.02, 95% CI 0.77 to 1.35, p=0.90). Conclusions Tranexamic acid was associated with improved clinical and radiological outcomes in ICH patients with baseline SBP≤170 mm Hg. Further research is needed to establish whether certain subgroups may benefit from tranexamic acid in acute ICH. Trial registration number ISRCTN93732214.
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Affiliation(s)
- Jason Philip Appleton
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Zhe Kang Law
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Neurology Unit, Department of Medicine, National University of Malaysia Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Lisa Jane Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | | | - Maia Beridze
- The First University Clinic, Tbilisi State Medical University, Tbilisi, Georgia
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Robert A Dineen
- Radiological Sciences, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Juan José Egea Guerrero
- Neurocritical Care Unit, Virgen del Rocio University Hospital, Sevilla, Spain
- IbiS, CSIC, University of Seville, Sevilla, Spain
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Michal Karlinski
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Philippe Lyrer
- Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Serefnur Ozturk
- Neurology, Faculty of Medicine, Selcuk Universitesi, Konya, Turkey
| | - Christine Roffe
- Stroke Research, School of Medicine, University of Keele, Stoke-on-Trent, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Polly Scutt
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Philip M Bath
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
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Prehospital transdermal glyceryl trinitrate in patients with presumed acute stroke (MR ASAP): an ambulance-based, multicentre, randomised, open-label, blinded endpoint, phase 3 trial. Lancet Neurol 2022; 21:971-981. [PMID: 36058230 DOI: 10.1016/s1474-4422(22)00333-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/12/2022] [Accepted: 07/26/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pooled analyses of previous randomised studies have suggested that very early treatment with glyceryl trinitrate (also known as nitroglycerin) improves functional outcome in patients with acute ischaemic stroke or intracerebral haemorrhage, but this finding was not confirmed in a more recent trial (RIGHT-2). We aimed to assess whether patients with presumed acute stroke benefit from glyceryl tr initrate started within 3 h after symptom onset. METHODS MR ASAP was a phase 3, randomised, open-label, blinded endpoint trial done at six ambulance services serving 18 hospitals in the Netherlands. Eligible participants (aged ≥18 years) had a probable diagnosis of acute stroke (as assessed by a paramedic), a face-arm-speech-time test score of 2 or 3, systolic blood pressure of at least 140 mm Hg, and could start treatment within 3 h of symptom onset. Participants were randomly assigned (1:1) by ambulance personnel, using a secure web-based electronic application with random block sizes stratified by ambulance service, to receive either transdermal glyceryl trinitrate 5 mg/day for 24 h plus standard care (glyceryl trinitrate group) or to standard care alone (control group) in the prehospital setting. Informed consent was deferred until after arrival at the hospital. The primary outcome was functional outcome assessed with the modified Rankin Scale (mRS) at 90 days. Safety outcomes included death within 7 days, death within 90 days, and serious adverse events. Analyses were based on modified intention to treat, and treatment effects were expressed as odds ratios (ORs) or common ORs, with adjustment for baseline prognostic factors. We separately analysed the total population and the target population (ie, patients with intracerebral haemorrhage, ischaemic stroke, or transient ischaemic attack). The target sample size was 1400 patients. The trial is registered as ISRCTN99503308. FINDINGS On June 24, 2021, the MR ASAP trial was prematurely terminated on the advice of the data and safety monitoring board, with recruitment stopped because of safety concerns in patients with intracerebral haemorrhage. Between April 4, 2018, and Feb 12, 2021, 380 patients were randomly allocated to a study group. 325 provided informed consent or died before consent could be obtained, of whom 170 were assigned to the glyceryl trinitrate group and 155 to the control group. These patients were included in the total population. 201 patients (62%) had ischaemic stroke, 34 (10%) transient ischaemic attack, 56 (17%) intracerebral haemorrhage, and 34 (10%) a stroke-mimicking condition. In the total population (n=325), the median mRS score at 90 days was 2 (IQR 1-4) in both the glyceryl trinitrate and control groups (adjusted common OR 0·97 [95% CI 0·65-1·47]). In the target population (n=291), the 90-day mRS score was 2 (2-4) in the glyceryl trinitrate group and 3 (1-4) in the control group (0·92 [0·59-1·43]). In the total population, there were no differences between the two study groups with respect to death within 90 days (adjusted OR 1·07 [0·53-2·14]) or serious adverse events (unadjusted OR 1·23 [0·76-1·99]). In patients with intracerebral haemorrhage, 12 (34%) of 35 patients allocated to glyceryl trinitrate versus two (10%) of 21 allocated to the control group died within 7 days (adjusted OR 5·91 [0·78-44·81]); death within 90 days occurred in 16 (46%) of 35 in the glyceryl trinitrate group and 11 (55%) of 20 in the control group (adjusted OR 0·87 [0·18-4·17]). INTERPRETATION We found no sign of benefit of transdermal glyceryl trinitrate started within 3 h of symptom onset in the prehospital setting in patients with presumed acute stroke. The signal of potential early harm of glyceryl trinitrate in patients with intracerebral haemorrhage suggests that glyceryl trinitrate should be avoided in this setting. FUNDING The Collaboration for New Treatments of Acute Stroke consortium, the Brain Foundation Netherlands, the Ministry of Economic Affairs, Stryker, Medtronic, Cerenovus, and the Dutch Heart Foundation.
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Lundberg JO, Weitzberg E. Nitric oxide signaling in health and disease. Cell 2022; 185:2853-2878. [DOI: 10.1016/j.cell.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 10/16/2022]
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Armario P, Garcia-Sánchez S, Cardona P. Management of high blood pressure in acute stroke. What is the right answer? HIPERTENSION Y RIESGO VASCULAR 2022; 39:145-148. [DOI: 10.1016/j.hipert.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 10/15/2022]
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Robinson TG, Minhas JS, Miller J. Review of major trials of acute blood pressure management in stroke. J Cereb Blood Flow Metab 2022; 42:404-410. [PMID: 33761781 PMCID: PMC8851668 DOI: 10.1177/0271678x211004310] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 02/02/2023]
Abstract
Over the last two decades, there have been a number of major landmark clinical trials, classified as "major" as they sought to address clear clinical practice driven questions, in a pragmatic yet robust trial design, using a large powered sample size (n > 1000), in order to help improve patient outcome through informing guidelines. A commonality across all stroke sub-types included in these trials is the tendency to acute hypertensive crises within the acute stroke period. This phenomenon is associated with greater stroke complications and worsened overall prognosis. Multiple trials have attempted to address the issue of acute blood pressure management during the acute stroke period, with consideration for timing, magnitude of lowering, agent and relationship to other interventions. This review will consider the major clinical trials performed in ischaemic and haemorrhagic stroke that test the hypothesis that acute BP reduction improves clinical outcomes.
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Affiliation(s)
- Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester,
Leicester, UK
- National Institute for Health Research Leicester Biomedical
Research Centre, The Glenfield Hospital, Leicester, UK
| | - Jatinder S Minhas
- Department of Cardiovascular Sciences, University of Leicester,
Leicester, UK
- National Institute for Health Research Leicester Biomedical
Research Centre, The Glenfield Hospital, Leicester, UK
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital and Wayne
State University, Detroit, MI, USA
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Berthaud JV, Morgenstern LB, Zahuranec DB. Medical Therapy of Intracerebral and Intraventricular Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00059-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lip GYH, Lane DA, Lenarczyk R, Boriani G, Doehner W, Benjamin LA, Fisher M, Lowe D, Sacco RL, Schnabel R, Watkins C, Ntaios G, Potpara T. OUP accepted manuscript. Eur Heart J 2022; 43:2442-2460. [PMID: 35552401 PMCID: PMC9259378 DOI: 10.1093/eurheartj/ehac245] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/11/2022] [Accepted: 04/27/2022] [Indexed: 11/12/2022] Open
Abstract
The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:
A: Appropriate Antithrombotic therapy. B: Better functional and psychological status. C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).
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Affiliation(s)
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Radosław Lenarczyk
- Division of Medical Sciences in Zabrze, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, The Medical University of Silesia, Silesian Center of Heart Diseases, Curie-Sklodowska Str 9, 41-800 Zabrze, Poland
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT) and Department of Internal Medicine and Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK) partner site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Laura A Benjamin
- Laboratory of Molecular and Cell Biology, University College London National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Deborah Lowe
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral CH49 5PE, UK
| | - Ralph L Sacco
- UM Clinical & Translational Science Institute, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Renate Schnabel
- University Heart & Vascular Center Hamburg Eppendorf, German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Caroline Watkins
- Faculty of Health and Care, University of Central Lancashire, Preston PR1 2HE, UK
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
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Lim BL, Lee WF, Ng WM, Situ W, Loo KV, Man Goh CJ, Chan WL. Benefits and safety of transdermal glyceryl trinitrate in acute stroke: A systematic review and meta-analysis of randomized trials. Acad Emerg Med 2021; 29:772-788. [PMID: 34741770 DOI: 10.1111/acem.14408] [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: 08/22/2021] [Revised: 10/21/2021] [Accepted: 10/31/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Transdermal glyceryl trinitrate (GTN) has potential beneficial properties in acute stroke including intracerebral hemorrhage (ICH) and possible clinical benefits suggested in ultra-early stroke (≤6 h). Our meta-analysis updated the evidence on its safety and benefits in acute stroke. METHODS We searched major electronic databases for randomized trials comparing transdermal GTN versus placebo/control in acute stroke. Primary outcomes were mortality, 90-day modified Rankin Scale (mRS), and blood pressure (BP) effects. Secondary outcomes included early, late, resource utilization, and surrogate outcomes. Safety outcomes were adverse events. Reviewers identified studies, extracted data, and assessed risk of bias (RoB) using a modified Cochrane RoB instrument and quality of evidence (QoE) using GRADE. We also performed a priori subgroup and trial sequential analyses (TSA) on primary outcomes. These subgroup analyses were ICH versus ischemic stroke, minor (NIHSS ≤5) versus major (NIHSS >5) ischemic stroke, ischemic stroke with versus without thrombolysis, prehospital versus non prehospital settings, time from stroke to randomization ≤6 h versus >6 h, and high versus low overall RoB studies. RESULTS Seven eligible primary trials enrolled 5363 patients. GTN reduced BP (mean difference [MD] = -4.74 mm Hg, 95% confidence interval [CI] = -6.03 to -3.45 mm Hg] and diastolic BP (MD = -2.94 mm Hg, 95% CI = -3.74 to -2.13 mm Hg) 24 h posttreatment but did not affect 4- to 10-day mortality (relative risk [RR] = 1.11, 95% CI = 0.82 to 1.49), 90-day mortality (RR = 0.96, 95% CI = 0.77 to 1.19), and 90-day mRS >2 (RR = 0.98, 95% CI = 0.93 to 1.03) compared to control/placebo. The QoE was high for primary outcomes with no subgroup effects detected. GTN did not affect secondary outcomes and increased risk of headache and hypotension. TSA generally supported our conclusions regarding primary outcomes. CONCLUSIONS Transdermal GTN reduces BP in acute stroke but does not alter clinical outcomes even in ultra-early stroke (≤6 h).
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Affiliation(s)
- Beng Leong Lim
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Wei Feng Lee
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Wei Ming Ng
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
- Unit for Pre‐hospital Emergency Care Ministry of Health Singapore
| | - Wangmin Situ
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Kee Vooi Loo
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Carmen Jia Man Goh
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Wui Ling Chan
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
- Disaster Medicine Ministry of Health Singapore
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Cai L, Rajah G, Duan H, Gao J, Cheng Z, Xin R, Jiang S, Palmer P, Geng X, Ding Y. Rapid Intravenous Glyceryl Trinitrate in Ischemic Damage (RIGID) After Stroke: Rationale, Design and Protocol for a Prospective Randomized Controlled Trial. Front Neurol 2021; 12:693330. [PMID: 34421796 PMCID: PMC8371530 DOI: 10.3389/fneur.2021.693330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Despite intravenous thrombolysis and endovascular therapy for acute ischemic stroke (AIS), many survivors still have varying degrees of disability. Glyceryl trinitrate (GTN), a nitric oxide (NO) donor, has been previously reported to induce neuroprotection after AIS. The use of GTN to reduce brain damage after stroke remains yet to be elucidated. This study was designed to explore the safety, feasibility, and preliminary efficacy of intravenous administration of GTN after AIS. Methods: A prospective randomized controlled trial is proposed with AIS patients. Participants will be randomly allocated to GTN group and control group with a 1:1 ratio (n = 40). Both groups will be treated with standard therapies according to the current stroke guidelines. Participants allocated to the GTN group will receive intravenous administration of GTN (5 mg GTN in 50 ml saline at a rate of 0.4 mg/h that is continued for 12.5 h/day for 2 days) within 24 h of symptom onset. Participants allocated to the control group will receive intravenous administration at equal capacity of 0.9% normal saline (NS) (total 50 ml/day at 4 ml/h that is continued for 12.5 h/day for 2 days). The primary outcome is safety [systolic blood pressure (SBP) <110 mmHg, headache], while the secondary outcomes include changes in functional outcome and infarction volume. Discussion: Rapid Intravenous Glyceryl Trinitrate in Ischemic Damage (RIGID) is a prospective randomized controlled trial that aims to ascertain the safety, feasibility, and preliminary efficacy of intravenous GTN as a neuroprotection strategy after AIS. These results will provide parameters for future studies as well as provide insights into treatment effects. Any possible neuroprotective qualities of GTN in AIS will also be elucidated. Trial Registration:www.chictr.org.cn, identifier: ChiCTR2100046271.
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Affiliation(s)
- Lipeng Cai
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Gary Rajah
- Department of Neurosurgery, Munson Medical Center, Traverse City, MI, United States
| | - Honglian Duan
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jie Gao
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zhe Cheng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Ruiqiang Xin
- Department of Medical Imaging, Luhe Hospital, Capital Medical University, Beijing, China
| | - Shangqian Jiang
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Peter Palmer
- Department of Neurology, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
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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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Hu E, Ding R, Li T, Li P, Feng D, Hu W, Cui H, Zhu X, Sun P, Wang Y, Tang T. Temporal metabolomic alteration in rat brains of experimental intracerebral hemorrhage. Brain Res Bull 2021; 170:234-245. [PMID: 33631271 DOI: 10.1016/j.brainresbull.2021.02.021] [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: 11/14/2020] [Revised: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is the top lethal and disabling form of stroke. The pathophysiology of ICH is not fully understood yet. Metabolites are indicators and regulators of cellular processes. However, the overall brain metabolic pattern and the temporal alterations after ICH remain unknown. METHODS A total of 40 male rats were randomly assigned to sham group and ICH group. ICH was induced by collagenase Ⅶ. Body weight was assessed. Neurological deficits were evaluated by modified neurological severity score. Then, the perihematomal brain tissues were collected for metabolites detection using high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS). The metabolic profiles were displayed by principal component analysis (PCA), partial least-squares-discriminant analysis (PLS-DA) and cluster analysis. The significant differential metabolites were screened by fold change > 2.0, the false discovery rate (FDR) < 0.05 and Variable Importance of Projection (VIP) > 1. Next, the relevant metabolic pathways were discerned by MetaboAnalyst website. A metabolite-protein interaction network was subsequentially constructed to further annotate the function of differential metabolites. RESULTS Rats suffered from compromised body weight increasement and impaired neurological function. The metabolomics profiles of brain tissues in the post-ICH rats were markedly different from those in the sham group on days 3 and 14. Thirty-four metabolites (bilirubin, uric acid, 6-Methylnicotinamide et al.) were abnormally upregulated in the acute stage, while 27 metabolites were disturbed in the recovery stage, including bilirubin, uric acid, and histamine et al. Seven and three metabolic pathways altered in the acute and recovery stage, respectively. Metabolite-protein interaction analysis revealed that the disturbed metabolites may participate in ICH pathophysiology by altering amino acid metabolism, peroxisome proliferators-activated receptor signaling pathway, fatty acid metabolism and urea cycle in the acute stage, while influencing amino acid metabolism, urea cycle and peroxisome in the recovery stage. CONCLUSIONS Our study mapped the pathological metabolomics profiles of the post-ICH rat brains in the acute and recovery phases. This work will assist in discovering novel therapeutic targets and treatments for ICH.
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Affiliation(s)
- En Hu
- Institute of Integrative Medicine, Department of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Ruoqi Ding
- Institute of Integrative Medicine, Department of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Teng Li
- Institute of Integrative Medicine, Department of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Pengfei Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, PR China
| | - Dandan Feng
- Institute of Integrative Medicine, Department of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Wang Hu
- Institute of Integrative Medicine, Department of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Hanjin Cui
- Institute of Integrative Medicine, Department of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Xiaofei Zhu
- Institute of Integrative Medicine, Department of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Peng Sun
- College of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, PR China
| | - Yang Wang
- Institute of Integrative Medicine, Department of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Tao Tang
- Institute of Integrative Medicine, Department of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha 410008, PR China.
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12
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Appleton JP, Krishnan K, Bath PM. Transdermal delivery of glyceryl trinitrate: clinical applications in acute stroke. Expert Opin Drug Deliv 2020; 17:297-303. [PMID: 31973594 DOI: 10.1080/17425247.2020.1716727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Glyceryl trinitrate (GTN), a nitric oxide donor, is a candidate treatment for the management of acute stroke with hemodynamic and potential reperfusion and neuroprotective effects.Areas covered: Here we discuss the evidence to date from clinical trials and present and future possibilities for the clinical application of transdermal GTN in acute stroke. When administered as a transdermal patch during the acute and subacute phases after stroke, GTN was safe, lowered blood pressure, maintained cerebral blood flow, and did not induce cerebral steal or alter functional outcome. However, when given within the hyperacute phase (<6 h of stroke onset), GTN reduced death and dependency, death, disability, cognitive impairment, and mood disturbance, and improved quality of life. However, in a large prehospital trial with treatment within 4 h, GTN did not influence clinical outcomes.Expert opinion: Transdermal GTN is an easy to administer BP-lowering therapy, which is safe when given after 2 h of stroke onset, may improve outcome when initiated within 2-6 h, but should be avoided (outside of a clinical trial) in the ultra-acute period within 2 h of stroke onset. Further research needs to investigate the mechanisms of benefit or harm in ultra/hyperacute stroke patients.
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Affiliation(s)
- Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Neurology, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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13
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Bath PM, Woodhouse LJ, Krishnan K, Appleton JP, Anderson CS, Berge E, Cala L, Dixon M, England TJ, Godolphin PJ, Hepburn T, Mair G, Montgomery AA, Phillips SJ, Potter J, Price CI, Randall M, Robinson TG, Roffe C, Rothwell PM, Sandset EC, Sanossian N, Saver JL, Siriwardena AN, Venables G, Wardlaw JM, Sprigg N. Prehospital Transdermal Glyceryl Trinitrate for Ultra-Acute Intracerebral Hemorrhage: Data From the RIGHT-2 Trial. Stroke 2019; 50:3064-3071. [PMID: 31587658 PMCID: PMC6824503 DOI: 10.1161/strokeaha.119.026389] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Supplemental Digital Content is available in the text. Pilot trials suggest that glyceryl trinitrate (GTN; nitroglycerin) may improve outcome when administered early after stroke onset.
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Affiliation(s)
- Philip M Bath
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
| | - Lisa J Woodhouse
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.)
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
| | - Jason P Appleton
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.)
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.S.A.).,The George Institute China at Peking University Health Science Center, Beijing, China (C.S.A.).,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, NSW, Australia (C.S.A.)
| | - Eivind Berge
- Department of Internal Medicine (E.B., A.N.S), Oslo University Hospital, Norway.,Department of Neurology (E.C.S.), Oslo University Hospital, Norway
| | - Lesley Cala
- Faculty of Health and Medical Sciences, University of Western Australia (L.C.)
| | - Mark Dixon
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,East Midlands Ambulance Service NHS Trust, Nottingham, United Kingdom (M.D.)
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences, GEM, Royal Derby Hospital Centre (T.J.E.), University of Nottingham, United Kingdom
| | - Peter J Godolphin
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Grant Mair
- Centre for Clinical Brain Sciences, Edinburgh Imaging and UK Dementia Research Institute at the University of Edinburgh, Chancellor's Building (G.M., J.M.W.)
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Stephen J Phillips
- Department of Medicine, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Canada (S.J.P.)
| | - John Potter
- Bob Champion Research and Education Building, University of East Anglia, Norwich, United Kingdom (J.P.)
| | - Chris I Price
- Institute of Neuroscience, Newcastle University, United Kingdom (C.I.P.)
| | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, United Kingdom (M.R.)
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, United Kingdom (T.G.R.)
| | - Christine Roffe
- Stroke Research in Stoke, Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, United Kingdom (C.R.)
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.M.R.)
| | - Else C Sandset
- Research and Development, The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S.)
| | - Nerses Sanossian
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles (N.S.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA (J.L.S.)
| | - A Niroshan Siriwardena
- Department of Internal Medicine (E.B., A.N.S), Oslo University Hospital, Norway.,Community and Health Research Unit, University of Lincoln, United Kingdom (A.N.S.)
| | - Graham Venables
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, United Kingdom (G.V.)
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, Edinburgh Imaging and UK Dementia Research Institute at the University of Edinburgh, Chancellor's Building (G.M., J.M.W.)
| | - Nikola Sprigg
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
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14
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Mandava P, Murthy SB, Shah N, Samson Y, Kimmel M, Kent TA. Pooled analysis suggests benefit of catheter-based hematoma removal for intracerebral hemorrhage. Neurology 2019; 92:e1688-e1697. [PMID: 30894441 DOI: 10.1212/wnl.0000000000007269] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 12/06/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To develop models of outcome for intracerebral hemorrhage (ICH) to identify promising and futile interventions based on their early phase results without need for correction for baseline imbalances. METHODS We developed a pooled outcome model from the control arms of randomized control trials and tested different interventions against the model at comparable baseline conditions. Eligible clinical trials and large case series were identified from multiple library databases. Models based on baseline factors reported in the control arms were tested for the ability to predict functional outcome (modified Rankin Scale score) and mortality. Interventions were grouped into blood pressure control, fibrinolytic-assisted hematoma evacuation, hemostatic medications, and neuroprotective agents. Statistical intervals around the model were generated at the p = 0.1 level to screen how each trial's outcome compared to expected outcome. RESULTS Fourteen control arms with 3,386 patients were used to develop 7 alternate models for functional outcome. The model incorporating baseline NIH Stroke Scale, age, and hematoma volume yielded the best fit (adjusted R 2 = 0.89). All early phase treatments that eventually resulted in negative late phase trials were identified as negative by this method. Early phase fibrinolytic-assisted hematoma evacuation studies showed the most promise trending toward improved functional outcome with no suggestion of an increase in mortality, supporting its further study. CONCLUSIONS We successfully developed an outcome model for ICH that identified interventions destined to be negative while identifying a promising one. Such an approach may assist in prioritizing resources prior to multicenter trial.
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Affiliation(s)
- Pitchaiah Mandava
- From the Michael E. DeBakey VA Medical Center Stroke Program (P.M., N.S.) and Analytical Software and Engineering Research Laboratory, Department of Neurology (P.M., N.S., T.A.K.), Baylor College of Medicine, Houston, TX; Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit (S.B.M.), Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY; APHP (Y.S.), Urgences Cerebro-Vasculaire, Pitié-Salpêtrière, and UPMC Paris Sorbonne Universités (Y.S.), Paris, France; Departments of Statistics and Bioengineering (M.K.) and Chemistry (T.A.K.), Rice University, Houston; Institute of Biosciences and Technology (IBT) (T.A.K.), Texas A&M Health Science Center-Houston Campus; and Department of Neurology (T.A.K.), Houston Methodist Hospital and Research Institute, TX.
| | - Santosh B Murthy
- From the Michael E. DeBakey VA Medical Center Stroke Program (P.M., N.S.) and Analytical Software and Engineering Research Laboratory, Department of Neurology (P.M., N.S., T.A.K.), Baylor College of Medicine, Houston, TX; Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit (S.B.M.), Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY; APHP (Y.S.), Urgences Cerebro-Vasculaire, Pitié-Salpêtrière, and UPMC Paris Sorbonne Universités (Y.S.), Paris, France; Departments of Statistics and Bioengineering (M.K.) and Chemistry (T.A.K.), Rice University, Houston; Institute of Biosciences and Technology (IBT) (T.A.K.), Texas A&M Health Science Center-Houston Campus; and Department of Neurology (T.A.K.), Houston Methodist Hospital and Research Institute, TX
| | - Neel Shah
- From the Michael E. DeBakey VA Medical Center Stroke Program (P.M., N.S.) and Analytical Software and Engineering Research Laboratory, Department of Neurology (P.M., N.S., T.A.K.), Baylor College of Medicine, Houston, TX; Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit (S.B.M.), Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY; APHP (Y.S.), Urgences Cerebro-Vasculaire, Pitié-Salpêtrière, and UPMC Paris Sorbonne Universités (Y.S.), Paris, France; Departments of Statistics and Bioengineering (M.K.) and Chemistry (T.A.K.), Rice University, Houston; Institute of Biosciences and Technology (IBT) (T.A.K.), Texas A&M Health Science Center-Houston Campus; and Department of Neurology (T.A.K.), Houston Methodist Hospital and Research Institute, TX
| | - Yves Samson
- From the Michael E. DeBakey VA Medical Center Stroke Program (P.M., N.S.) and Analytical Software and Engineering Research Laboratory, Department of Neurology (P.M., N.S., T.A.K.), Baylor College of Medicine, Houston, TX; Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit (S.B.M.), Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY; APHP (Y.S.), Urgences Cerebro-Vasculaire, Pitié-Salpêtrière, and UPMC Paris Sorbonne Universités (Y.S.), Paris, France; Departments of Statistics and Bioengineering (M.K.) and Chemistry (T.A.K.), Rice University, Houston; Institute of Biosciences and Technology (IBT) (T.A.K.), Texas A&M Health Science Center-Houston Campus; and Department of Neurology (T.A.K.), Houston Methodist Hospital and Research Institute, TX
| | - Marek Kimmel
- From the Michael E. DeBakey VA Medical Center Stroke Program (P.M., N.S.) and Analytical Software and Engineering Research Laboratory, Department of Neurology (P.M., N.S., T.A.K.), Baylor College of Medicine, Houston, TX; Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit (S.B.M.), Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY; APHP (Y.S.), Urgences Cerebro-Vasculaire, Pitié-Salpêtrière, and UPMC Paris Sorbonne Universités (Y.S.), Paris, France; Departments of Statistics and Bioengineering (M.K.) and Chemistry (T.A.K.), Rice University, Houston; Institute of Biosciences and Technology (IBT) (T.A.K.), Texas A&M Health Science Center-Houston Campus; and Department of Neurology (T.A.K.), Houston Methodist Hospital and Research Institute, TX
| | - Thomas A Kent
- From the Michael E. DeBakey VA Medical Center Stroke Program (P.M., N.S.) and Analytical Software and Engineering Research Laboratory, Department of Neurology (P.M., N.S., T.A.K.), Baylor College of Medicine, Houston, TX; Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit (S.B.M.), Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY; APHP (Y.S.), Urgences Cerebro-Vasculaire, Pitié-Salpêtrière, and UPMC Paris Sorbonne Universités (Y.S.), Paris, France; Departments of Statistics and Bioengineering (M.K.) and Chemistry (T.A.K.), Rice University, Houston; Institute of Biosciences and Technology (IBT) (T.A.K.), Texas A&M Health Science Center-Houston Campus; and Department of Neurology (T.A.K.), Houston Methodist Hospital and Research Institute, TX
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15
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Abstract
Intracerebral hemorrhage (ICH) is responsible for approximately 15% of strokes annually in the United States, with nearly 1 in 3 of these patients dying without ever leaving the hospital. Because this disproportionate mortality risk has been stagnant for nearly 3 decades, a main area of research has been focused on the optimal strategies to reduce mortality and improve functional outcomes. The acute hypertensive response following ICH has been shown to facilitate ICH expansion and is a strong predictor of mortality. Rapidly reducing blood pressure was once thought to induce cerebral ischemia, though has been found to be safe in certain patient populations. Clinicians must work quickly to determine whether specific patient populations may benefit from acute lowering of systolic blood pressure (SBP) following ICH. This review provides nurses with a summary of the available literature on blood pressure control following ICH. It focuses on intravenous and oral antihypertensive medications available in the United States that may be utilized to acutely lower SBP, as well as medications outside of the antihypertensive class used during the acute setting that may reduce SBP.
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16
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Pszczolkowski S, Law ZK, Gallagher RG, Meng D, Swienton DJ, Morgan PS, Bath PM, Sprigg N, Dineen RA. Automated segmentation of haematoma and perihaematomal oedema in MRI of acute spontaneous intracerebral haemorrhage. Comput Biol Med 2019; 106:126-139. [PMID: 30711800 PMCID: PMC6382492 DOI: 10.1016/j.compbiomed.2019.01.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 11/19/2022]
Abstract
Background Spontaneous intracerebral haemorrhage (SICH) is a common condition with high morbidity and mortality. Segmentation of haematoma and perihaematoma oedema on medical images provides quantitative outcome measures for clinical trials and may provide important markers of prognosis in people with SICH. Methods We take advantage of improved contrast seen on magnetic resonance (MR) images of patients with acute and early subacute SICH and introduce an automated algorithm for haematoma and oedema segmentation from these images. To our knowledge, there is no previously proposed segmentation technique for SICH that utilises MR images directly. The method is based on shape and intensity analysis for haematoma segmentation and voxel-wise dynamic thresholding of hyper-intensities for oedema segmentation. Results Using Dice scores to measure segmentation overlaps between labellings yielded by the proposed algorithm and five different expert raters on 18 patients, we observe that our technique achieves overlap scores that are very similar to those obtained by pairwise expert rater comparison. A further comparison between the proposed method and a state-of-the-art Deep Learning segmentation on a separate set of 32 manually annotated subjects confirms the proposed method can achieve comparable results with very mild computational burden and in a completely training-free and unsupervised way. Conclusion Our technique can be a computationally light and effective way to automatically delineate haematoma and oedema extent directly from MR images. Thus, with increasing use of MR images clinically after intracerebral haemorrhage this technique has the potential to inform clinical practice in the future. A fast method for detection of haematoma and oedema in haemorrhagic stroke is presented. To our knowledge, it is the first method to use magnetic resonance images only. The introduced method is fully automated, training-free and unsupervised. Comparable results with respect to human expert annotations are achieved. Method has potential to inform clinical practice, with increased clinical MRI use.
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Affiliation(s)
- Stefan Pszczolkowski
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK; Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, UK.
| | - Zhe K Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK; Department of Medicine, National University of Malaysia, Malaysia.
| | - Rebecca G Gallagher
- Department of Neuroradiology, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK; Department of Radiology, Royal Derby Hospital, Derby, UK.
| | - Dewen Meng
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, UK.
| | - David J Swienton
- Department of Neuroradiology, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK; Imaging Department, Leicester Royal Infirmary, Leicester, UK.
| | - Paul S Morgan
- Medical Physics and Clinical Engineering, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK.
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK.
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK.
| | - Rob A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, UK; NIHR Nottingham BRC, UK.
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17
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Effects of vasodilating medications on cerebral haemodynamics in health and disease: systematic review and meta-analysis. J Hypertens 2018; 37:1119-1125. [PMID: 30540658 PMCID: PMC6513078 DOI: 10.1097/hjh.0000000000002033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives: Vasodilating antihypertensives prevent stroke and potentially cerebral small vessel disease but their effects on cerebrovascular haemodynamics beyond blood pressure lowering are unclear. Methods: We searched PubMed, Medline, Embase, Cinahl, Psychinfo, Health Business Elite and Health Management Information Consortium for randomized studies of vasodilating medications, compared to no treatment or nonvasodilators, that reported effects on cerebral blood flow (CBF), mean blood flow velocity (MFV) or cerebrovascular reactivity. Absolute and standardized mean differences (SMD) were combined by inverse-variance weighted fixed or random-effects meta-analysis stratified by study design, population characteristics and vasodilator class. Results: In 35 studies reporting 57 comparisons, there was a reduction in SBP (−4.13 mmHg, −7.55 to −0.71, P = 0.018) but no change in MFV (ΔMFV 1.11, confidence interval −0.93 to 3.14, P = 0.29, 23 comparisons). MFV increased in patients with underlying conditions (3.41, 0.24 to 6.57, P = 0.04) but not in healthy study participants (−1.27, −5.18 to 2.64, P = 0.68), with no differences by vasodilating drug class. Cerebral pulsatility index was reduced across all studies (Δ pulsatility index −0.04, −0.07 to −0.02, P = 0.001; Δ pulsatility index -SMD −0.32, −0.47 to −0.16, P < 0.001), except in studies reporting responses to single drug doses (Δ pulsatility index 0.00, −0.09 to −0.08, P = 0.93). Despite evidence of reporting and publication bias, there was an apparent consistent reduction in CBF with vasodilators (CBF-SMD −0.24, −0.46 to −0.02, P = 0.03) with a significant increase in cerebrovascular reactivity-SMD (0.48, 0.13–0.83, P = 0.007). Conclusions: Despite reducing SBP, vasodilators did not significantly impair absolute CBF but improved cerebrovascular pulsatility and reactivity, suggesting therapeutic potential in preventing stroke and cerebral small vessel disease.
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18
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Qureshi AI, Qureshi MH. Acute hypertensive response in patients with intracerebral hemorrhage pathophysiology and treatment. J Cereb Blood Flow Metab 2018; 38:1551-1563. [PMID: 28812942 PMCID: PMC6125978 DOI: 10.1177/0271678x17725431] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute hypertensive response is a common systemic response to occurrence of intracerebral hemorrhage which has gained unique prominence due to high prevalence and association with hematoma expansion and increased mortality. Presumably, the higher systemic blood pressure predisposes to continued intraparenchymal hemorrhage by transmission of higher pressure to the damaged small arteries and may interact with hemostatic and inflammatory pathways. Therefore, intensive reduction of systolic blood pressure has been evaluated in several clinical trials as a strategy to reduce hematoma expansion and subsequent death and disability. These trials have demonstrated either a small magnitude benefit (second intensive blood pressure reduction in acute cerebral hemorrhage trial and efficacy of nitric oxide in stroke trial) or no benefit (antihypertensive treatment of acute cerebral hemorrhage 2 trial) with intensive systolic blood pressure reduction compared with modest or standard blood pressure reduction. The differences may be explained by the variation in intensity of systolic blood pressure reduction between trials. A treatment threshold of systolic blood pressure of ≥180 mm with the target goal of systolic blood pressure reduction to values between 130 and 150 mm Hg within 6 h of symptom onset may be best supported by current evidence.
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19
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Sandset EC, Sanossian N, Woodhouse LJ, Anderson C, Berge E, Lees KR, Potter JF, Robinson TG, Sprigg N, Wardlaw JM, Bath PM. Protocol for a prospective collaborative systematic review and meta-analysis of individual patient data from randomized controlled trials of vasoactive drugs in acute stroke: The Blood pressure in Acute Stroke Collaboration, stage-3. Int J Stroke 2018; 13:759-765. [DOI: 10.1177/1747493018772733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rationale Despite several large clinical trials assessing blood pressure lowering in acute stroke, equipoise remains particularly for ischemic stroke. The “Blood pressure in Acute Stroke Collaboration” commenced in the mid-1990s focussing on systematic reviews and meta-analysis of blood pressure lowering in acute stroke. From the start, Blood pressure in Acute Stroke Collaboration planned to assess safety and efficacy of blood pressure lowering in acute stroke using individual patient data. Aims To determine the optimal management of blood pressure in patients with acute stroke, including both intracerebral hemorrhage and ischemic stroke. Secondary aims are to assess which clinical and therapeutic factors may alter the optimal management of high blood pressure in patients with acute stroke and to assess the effect of vasoactive treatments on hemodynamic variables. Methods and design Individual patient data from randomized controlled trials of blood pressure management in participants with ischemic stroke and/or intracerebral hemorrhage enrolled during the ultra-acute (pre-hospital), hyper-acute (<6 h), acute (<48 h), and sub-acute (<168 h) phases of stroke. Study outcomes The primary effect variable will be functional outcome defined by the ordinal distribution of the modified Rankin Scale; analyses will also be carried out in pre-specified subgroups to assess the modifying effects of stroke-related and pre-stroke patient characteristics. Key secondary variables will include clinical, hemodynamic and neuroradiological variables; safety variables will comprise death and serious adverse events. Discussion Study questions will be addressed in stages, according to the protocol, before integrating these into a final overreaching analysis. We invite eligible trials to join the collaboration.
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Affiliation(s)
| | - Nerses Sanossian
- Department of Neurology, University of Southern California, Los Angeles, USA
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Craig Anderson
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Kennedy R Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - John F Potter
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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20
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Effects of Intensive Blood Pressure Reduction on Acute Intracerebral Hemorrhage: A Systematic Review and Meta-analysis. Sci Rep 2017; 7:10694. [PMID: 28878305 PMCID: PMC5587814 DOI: 10.1038/s41598-017-10892-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 08/16/2017] [Indexed: 12/26/2022] Open
Abstract
Current opinions about the effect of intensive blood pressure (BP) reduction for acute intracerebral hemorrhage (ICH) are inconsistent. We performed a meta-analysis to evaluate the efficacy and safety of intensive BP reduction for acute ICH by analyzing data from several recent randomized controlled trials (RCTs). There were six eligible studies that met the inclusion criteria, for a total of 4,385 acute ICH patients in this meta-analysis. After analyzing these data, we found differences between intensive and standard BP lowering treatment groups in total mortality rates, unfavorable outcomes, hematoma expansion, neurologic deterioration, and severe hypotension were not significant. Moreover, compared with the standard treatment, the rate of renal adverse event in intensive treatment group was significantly higher. The intensive treatment approach was recommended in the following situations: (1) longer prehospital duration; (2) lower National Institute of Health stroke scale (NIHSS) score; (3) no hypertension history.
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21
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Wynne BM, Labazi H, Carneiro ZN, Tostes RC, Webb RC. Angeli's Salt, a nitroxyl anion donor, reverses endothelin-1 mediated vascular dysfunction in murine aorta. Eur J Pharmacol 2017; 814:294-301. [PMID: 28830679 DOI: 10.1016/j.ejphar.2017.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 08/15/2017] [Accepted: 08/18/2017] [Indexed: 10/19/2022]
Abstract
Nitroglycerin (Gtn) is a treatment for cardiovascular patients due to its vasodilatory actions, but induces tolerance when given chronically. A proposed mechanism is the superoxide (O2-)-oxidative stress hypothesis, which suggests that Gtn increases O2- production. Nitric oxide (NO) exists in three different redox states; the protonated, reduced state, nitroxyl anion (HNO) is an emerging candidate in vascular regulation. HNO is resistant to scavenging and of particular interest in conditions where high levels of reactive oxygen species (ROS) exist. We hypothesize that treatment with Gtn will exacerbate endothelin 1 (ET-1) induced vascular dysfunction via an increase in ROS, while treatment with Angeli's Salt (AS), an HNO donor, will not. Aorta from mice were isolated and divided into four groups: vehicle, ET-1 [0.1μM, 1μM], ET-1+Gtn [Gtn 1μM] and ET-1+AS [AS 1μM]. Concentration response curves (CRCs) to acetylcholine (ACh) and phenylephrine (Phe) were performed. Aorta incubated with ET-1 (for 20-22h) exhibited a decreased relaxation response to ACh and an increase in Phe-mediated contraction. Aorta incubated with AS exhibited a reversal in ET-1 induced vascular and endothelial dysfunction. ET-1 increased ROS in aortic vascular smooth muscle cells (VSMCs), visualized by dihydroethidium (DHE) staining. AS incubated reduced this ROS generation, yet maintained with Gtn treatment. These data suggest that aorta incubated with the HNO donor, AS, can reverse ET-1 mediated vascular dysfunction, which may be through a decrease or prevention of ROS generation. We propose that HNO may be vasoprotective and that HNO donors studied as a therapeutic option where other organic nitrates are contraindicative.
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Affiliation(s)
- Brandi M Wynne
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States; Department of Medicine, Renal Division, Emory University, 615 Michael St. Ste 605C, Atlanta, GA 30322, United States.
| | - Hicham Labazi
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States; Center for Cardiovascular Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH 43215, United States.
| | - Zidonia N Carneiro
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States.
| | - Rita C Tostes
- Pharmacology Department, Medical School of Ribeirão Preto, University of São Paulo, Av Bandeirantes 3900, Ribeirão Preto, SP 14049-900, Brazil.
| | - R Clinton Webb
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States.
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22
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Abstract
Managing acute intracerebral haemorrhage is a challenging task for physicians. Evidence shows that outcome can be improved with admission to an acute stroke unit and active care, including urgent reversal of anticoagulant effects and, potentially, intensive blood pressure reduction. Nevertheless, many management issues remain controversial, including the use of haemostatic therapy, selection of patients for neurosurgery and neurocritical care, the extent of investigations for underlying causes and the benefit versus risk of restarting antithrombotic therapy after an episode of intracerebral haemorrhage.
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Affiliation(s)
- Zhe Kang Law
- University of Nottingham, UK
- National University of Malaysia, Kuala Lumpur, Malaysia
| | | | - Philip M Bath
- University of Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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23
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Abstract
The nitric oxide donor, glyceryl trinitrate (GTN), is a candidate treatment for the management of acute stroke with haemodynamic and potential reperfusion and neuroprotective effects. When administered as a transdermal patch during the acute and subacute phases after stroke, GTN was safe, lowered blood pressure, maintained cerebral blood flow, and did not induce cerebral steal or alter functional outcome. However, when given within 6 h of stroke onset, GTN reduced death and dependency (odds ratio 0.52; 95% confidence interval 0.34-0.78), death, disability, cognitive impairment and mood disturbance, and improved quality of life (data from two trials, n = 312). In a pooled analysis of four studies (n = 186), GTN reduced between-visit systolic blood pressure variability over days 1-7 compared with no GTN (mean difference -2.09; 95% confidence interval -3.83 to -0.35; p = 0.019). The efficacy of GTN given in the ultra-acute/pre-hospital setting is currently being assessed and, if found to be beneficial, the implications for hyperacute stroke practice are significant. Here, we discuss the evidence to date, potential mechanisms of action and future possibilities, including unanswered questions, for the therapeutic potential of GTN in acute stroke.
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Appleton JP, Sprigg N, Bath PM. Blood pressure management in acute stroke. Stroke Vasc Neurol 2016; 1:72-82. [PMID: 28959467 PMCID: PMC5435190 DOI: 10.1136/svn-2016-000020] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/20/2016] [Accepted: 05/21/2016] [Indexed: 01/05/2023] Open
Abstract
Blood pressure (BP) is elevated in 75% or more of patients with acute stroke and is associated with poor outcomes. Whether to modulate BP in acute stroke has long been debated. With the loss of normal cerebral autoregulation, theoretical concerns are twofold: high BP can lead to cerebral oedema, haematoma expansion or haemorrhagic transformation; and low BP can lead to increased cerebral infarction or perihaematomal ischaemia. Published evidence from multiple large, high-quality, randomised trials is increasing our understanding of this challenging area, such that BP lowering is recommended in acute intracerebral haemorrhage and is safe in ischaemic stroke. Here we review the evidence for BP modulation in acute stroke, discuss the issues raised and look to on-going and future research to identify patient subgroups who are most likely to benefit.
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Affiliation(s)
- Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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