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Li J, Liu BJ, Wang YJ, Cui Y, Chen HS. Antihypertensive Drugs Affect the Association of Systolic Blood Pressure Variability with Outcomes in Patients with Acute Stroke who had Successful Recanalization after Endovascular Treatment. J Atheroscler Thromb 2024; 31:616-625. [PMID: 38220185 PMCID: PMC11079479 DOI: 10.5551/jat.64637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/05/2023] [Indexed: 01/16/2024] Open
Abstract
AIMS Blood pressure variability (BPV) was associated with the clinical outcomes in patients with acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) after endovascular treatment (EVT). This study aimed to investigate whether the use of antihypertensive drugs could affect this association in patients with AIS-LVO after EVT. METHODS We retrospectively screened consecutive patients with AIS-LVO who had successful recanalization after EVT and calculated their systolic BPV (SBPV) during the first 24 h after EVT using eight statistical methodologies based on previously published literature. Poor outcome was defined as a modified Rankin Scale score of 3-6 at 90 days. Logistic regression analysis was performed to assess this association, and different prediction models were constructed to assess the effect of the use of antihypertensive drugs. RESULTS A total of 214 patients were finally included, including 92 (43.0%) with good outcomes, and 136 (63.6%) who received antihypertensive drugs. SBPV indicators were significantly lower in patients with good outcomes versus those with poor outcomes. The logistic analysis showed that all SBPV indicators were consistently associated with poor outcomes (odds ratio, 1.031-1.282, all P<0.05) in all populations, which was confirmed in patients not using antihypertensive drugs. However, no SBPV indicator was found to be associated with poor outcomes in patients using antihypertensive drugs. Receiver operating characteristic curves showed that the area under the curve (AUC) was larger in the model adjusting for antihypertensive drugs (AUC 0.774-0.783) compared with the one not adjusted for antihypertensive drugs (AUC 0.739-0.754). CONCLUSION In the anterior circulation of patients with AIS-LVO who had successful recanalization after EVT, the utilization of antihypertensive drugs may have some impact on the relationship between SBPV and clinical outcomes.
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Affiliation(s)
- Jing Li
- Department of Neurology, General Hospital of Northern Theater Command; Shenyang, China
| | - Bai-Jun Liu
- Department of Neurology, General Hospital of Northern Theater Command; Shenyang, China
| | - Ying-Jia Wang
- Department of Neurology, General Hospital of Northern Theater Command; Shenyang, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command; Shenyang, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command; Shenyang, 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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Wang H, Guo Y, Xu J, Sun Y, Ji Y, Xu X, Yang Q, Huang X, Zhou Z. Blood pressure variability and outcome in atherosclerosis versus cardioembolism cerebral large vessel occlusion after successful thrombectomy. Hypertens Res 2024; 47:898-909. [PMID: 37978233 DOI: 10.1038/s41440-023-01500-x] [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: 03/02/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
Higher blood pressure variability (BPV) has been proven associated with worse functional outcome after endovascular treatment (EVT). However, this association is not established according to different stroke etiologies. In this study, we compared patients with the two highest proportions of stroke etiologies-cardioembolism (CE) and large-artery atherosclerosis (LAA), aiming to explore appropriate strategies of BP management for different etiologies. We enrolled patients with large vessel occlusion (LVO) in anterior circulation who underwent EVT and achieved successful recanalization retrospectively. 24-h blood pressure (BP) and BPV measured as blood pressure reduction (BPr), standard deviation (SD), coefficient of variation (CV), successive variation (SV), average real variability (ARV) after EVT were collected for systolic blood pressure (SBP) and diastolic blood pressure (DBP). The favorable outcome was defined as functional independence by 90-day modified Rankin Scale (mRS 0-2). In our cohort, higher BPV parameters significantly resulted in 90d functional dependence in CE-LVO patients (SBPSV OR: 1.083, 95%CI = 1.009-1.163; SBPARV OR: 1.121, 95%CI = 1.019-1.233; DBPSD OR: 1.124, 95%CI = 1.007-1.1256; DBPCV OR: 1.078, 95%CI = 1.002-1.161). However, for LAA-LVO patients, no positive results correlated 90d functional dependence with 24-hour BPV. Additionally, 90d functional dependence in CE patients with poor collaterals were significantly dependent on post-procedural BPV (DBPmax OR: 1.044, 95%CI = 1.002-1.087; DBPSD OR: 1.229, 95%CI = 1.022-1.1.479; DBPCV OR: 1.143, 95%CI = 1.009-1.295). Whereas to patients with good collaterals, there did not exist such a correlation. In summary, stroke etiologies should probably be taken into consideration to optimize individualized BP management strategies. In order to achieve better clinical outcomes for patients with acute ischemic stroke due to large vessel occlusion, stricter blood pressure management should be taken in cardioembolic stroke patients in contrast with large artery atherosclerotic stroke patients after successful endovascular therapy.
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Affiliation(s)
- Hao Wang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yapeng Guo
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Junfeng Xu
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yi Sun
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yachen Ji
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xiangjun Xu
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Qian Yang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xianjun Huang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China.
| | - Zhiming Zhou
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China.
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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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6
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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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Li Y, Schappell LE, Polizu C, DiPersio J, Tsirka SE, Halterman MW, Nadkarni NA. Evolving Clinical-Translational Investigations of Cerebroprotection in Ischemic Stroke. J Clin Med 2023; 12:6715. [PMID: 37959180 PMCID: PMC10649331 DOI: 10.3390/jcm12216715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
Ischemic stroke is a highly morbid disease, with over 50% of large vessel stroke (middle cerebral artery or internal carotid artery terminus occlusion) patients suffering disability despite maximal acute reperfusion therapy with thrombolysis and thrombectomy. The discovery of the ischemic penumbra in the 1980s laid the foundation for a salvageable territory in ischemic stroke. Since then, the concept of neuroprotection has been a focus of post-stroke care to (1) minimize the conversion from penumbra to core irreversible infarct, (2) limit secondary damage from ischemia-reperfusion injury, inflammation, and excitotoxicity and (3) to encourage tissue repair. However, despite multiple studies, the preclinical-clinical research enterprise has not yet created an agent that mitigates post-stroke outcomes beyond thrombolysis and mechanical clot retrieval. These translational gaps have not deterred the scientific community as agents are under continuous investigation. The NIH has recently promoted the concept of cerebroprotection to consider the whole brain post-stroke rather than just the neurons. This review will briefly outline the translational science of past, current, and emerging breakthroughs in cerebroprotection and use of these foundational ideas to develop a novel paradigm for optimizing stroke outcomes.
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Affiliation(s)
- Yinghui Li
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
| | - Laurel E. Schappell
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
- Department of Pharmacological Sciences, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA;
| | - Claire Polizu
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
| | - James DiPersio
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
| | - Stella E. Tsirka
- Department of Pharmacological Sciences, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA;
| | - Marc W. Halterman
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
| | - Neil A. Nadkarni
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
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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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Luby M, Hsia AW, Lomahan CA, Davis R, Burton S, Kim Y, Craft V, Uche V, Cabatbat R, Adil MM, Thomas LC, De Vis JB, Afzal MM, McGavern D, Lynch JK, Leigh R, Latour LL. Post-ischemic hyperemia following endovascular therapy for acute stroke is associated with lesion growth. J Cereb Blood Flow Metab 2023; 43:856-868. [PMID: 36748316 PMCID: PMC10196753 DOI: 10.1177/0271678x231155222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 02/08/2023]
Abstract
A substantial proportion of acute stroke patients fail to recover following successful endovascular therapy (EVT) and injury to the brain and vasculature secondary to reperfusion may be a contributor. Acute stroke patients were included with: i) large vessel occlusion of the anterior circulation, ii) successful recanalization, and iii) evaluable MRI early after EVT. Presence of hyperemia on MRI perfusion was assessed by consensus using a modified ASPECTS. Three different approaches were used to quantify relative cerebral blood flow (rCBF). Sixty-seven patients with median age of 66 [59-76], 57% female, met inclusion criteria. Hyperemia was present in 35/67 (52%) patients early post-EVT, in 32/65 (49%) patients at 24 hours, and in 19/48 (40%) patients at 5 days. There were no differences in incomplete reperfusion, HT, PH-2, HARM, severe HARM or symptomatic ICH rates between those with and without early post-EVT hyperemia. A strong association (R2 = 0.81, p < 0.001) was found between early post-EVT hyperemia (p = 0.027) and DWI volume at 24 hours after adjusting for DWI volume at 2 hours (p < 0.001) and incomplete reperfusion at 24 hours (p = 0.001). Early hyperemia is a potential marker for cerebrovascular injury and may help select patients for adjunctive therapy to prevent edema, reperfusion injury, and lesion growth.
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Affiliation(s)
- Marie Luby
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
| | - Amie W Hsia
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- MedStar Washington Hospital Center
Comprehensive Stroke Center, Washington, DC, USA
| | - Carolyn A Lomahan
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- Suburban Hospital, Johns Hopkins
Medicine, Bethesda, MD, USA
| | - Rachel Davis
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- Suburban Hospital, Johns Hopkins
Medicine, Bethesda, MD, USA
| | - Shannon Burton
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- MedStar Washington Hospital Center
Comprehensive Stroke Center, Washington, DC, USA
| | - Yongwoo Kim
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- MedStar Washington Hospital Center
Comprehensive Stroke Center, Washington, DC, USA
| | - Veronica Craft
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- MedStar Washington Hospital Center
Comprehensive Stroke Center, Washington, DC, USA
| | - Victoria Uche
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- MedStar Washington Hospital Center
Comprehensive Stroke Center, Washington, DC, USA
| | - Rainier Cabatbat
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- MedStar Washington Hospital Center
Comprehensive Stroke Center, Washington, DC, USA
| | - Malik M Adil
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- Suburban Hospital, Johns Hopkins
Medicine, Bethesda, MD, USA
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - Leila C Thomas
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- Suburban Hospital, Johns Hopkins
Medicine, Bethesda, MD, USA
| | - Jill B De Vis
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- Department of Radiation Oncology,
Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Dorian McGavern
- NIH/NINDS Viral Immunology and
Intravital Imaging Section, Bethesda, MD, USA
| | | | - Richard Leigh
- NIH/NINDS, Stroke Branch, Bethesda,
MD, USA
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
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10
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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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11
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DiNitto J, Feldman M, Grimaudo H, Mummareddy N, Ahn S, Bhamidipati A, Anderson D, Ramirez-Giraldo JC, Fusco M, Chitale R, Froehler MT. Flat-panel dual-energy head computed tomography in the angiography suite after thrombectomy for acute stroke: A clinical feasibility study. Interv Neuroradiol 2023:15910199231157462. [PMID: 36788203 DOI: 10.1177/15910199231157462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Management of large vessel occlusion (LVO) patients after thrombectomy is affected by the presence of intracranial hemorrhage (ICH) on post-procedure imaging. Differentiating contrast staining from hemorrhage on post-procedural imaging has been facilitated by dual-energy computed tomography (DECT), traditionally performed in dedicated computed tomography (CT) scanners with subsequent delays in treatment. We employed a novel method of DECT using the Siemens cone beam CT (DE-CBCT) in the angiography suite to evaluate for post-procedure ICH and contrast extravasation. METHODS After endovascular treatment for LVO was performed and before the patient was removed from the operating table, DE-CBCT was performed using the Siemens Q-biplane system, with two separate 20-second CBCT scans at two energy levels: 70 keV (standard) and 125 keV with tin filtration (nonstandard). Post-procedurally, patients also underwent a standard DECT using Siemens SOMATOM Force CT scanner. Two independent reviewers blindly evaluated the DE-CBCT and DECT for hemorrhage and contrast extravasation. RESULTS We successfully performed intra-procedural DE-CBCT in 10 subjects with no technical failure. The images were high-quality and subjectively useful to differentiate contrast from hemorrhage. The one hemorrhage seen on standard DECT was very small and clinically silent. The interrater reliability was 100% for both contrast and hemorrhage detection. CONCLUSION We demonstrate that intra-procedural DE-CBCT after thrombectomy is feasible and provides clinically meaningful images. There was close agreement between findings on DE-CBCT and standard DECT. Our findings suggest that DE-CBCT could be used in the future to improve stroke thrombectomy patient workflow and to more efficiently guide the postoperative management of these patients.
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Affiliation(s)
- Julie DiNitto
- 33573Siemens Medical Solutions, Malvern, PA, USA
- Department of Neurosurgery, 12326University of Tennessee Health and Science Center, Memphis, TN, USA
| | - Michael Feldman
- Department of Neurological Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Heather Grimaudo
- Department of Neurological Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nishit Mummareddy
- Department of Neurological Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Seoiyoung Ahn
- 12327Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Drew Anderson
- Cerebrovascular Program, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Matthew Fusco
- Department of Neurological Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
- Cerebrovascular Program, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rohan Chitale
- Department of Neurological Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
- Cerebrovascular Program, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael T Froehler
- Department of Neurological Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
- Cerebrovascular Program, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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12
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Lin CJ, Chung CP, Cheng HM, Liu CH, Hsu LC, Chi NF, Tang SC, Lee JT, Po HL, Jeng JS, Wang TD, Lee IH. The 2020 Taiwan Stroke Society guidelines for blood pressure control at the acute stage of ischemic stroke. J Formos Med Assoc 2023; 122:98-105. [PMID: 36041989 DOI: 10.1016/j.jfma.2022.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 03/11/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023] Open
Abstract
The 2020 Taiwan Stroke Society (TSS) guidelines for blood pressure (BP) control related to ischemic stroke update the 2015 TSS BP guidelines. The early management of acute ischemic stroke has evolved rapidly in the previous two decades. Since the publication of the previous version of the TSS BP guidelines, many studies have addressed BP management in ischemic stroke. Particularly, several successful endovascular thrombectomy (EVT) trials published in 2015 led to a new era of acute treatment for ischemic stroke. With the ever-increasing use of EVT, evidence-based guidelines for ideal BP management during and after EVT are urgently needed. Consequently, the 2020 guidelines are updating and providing recommendations on BP control for the treatment and prevention of ischemic stroke based on new evidence. The present study encompasses the most important chapter of the 2020 Taiwan BP guidelines: BP control at the acute stage of ischemic stroke. We incorporated the most updated evidence regarding BP control at the acute stage of ischemic stroke in patients receiving or not receiving acute reperfusion therapy and provided specific recommendations for different treatment subgroups accordingly.
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Affiliation(s)
- Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Chih-Ping Chung
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.
| | - Hao-Ming Cheng
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Institute of Public Health, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Center for Evidence-based Medicine & Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chi-Hung Liu
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Li-Chi Hsu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Nai-Fang Chi
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, Taipei, Taiwan
| | - Helen L Po
- Department of Neurology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzung-Dau Wang
- Department of Cardiology, National Taiwan University, Taipei, Taiwan
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
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13
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Lai Y, Jou E, Mofatteh M, Nguyen TN, Ho JSY, Diana F, Dmytriw AA, He J, Yan W, Chen Y, Yan Z, Sun H, Yeo LL, Chen Y, Zhou S. 7-Day National Institutes of Health Stroke Scale as a surrogate marker predicting ischemic stroke patients' outcome following endovascular therapy. Transl Neurosci 2023; 14:20220307. [PMID: 37873059 PMCID: PMC10590605 DOI: 10.1515/tnsci-2022-0307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/26/2023] [Accepted: 09/05/2023] [Indexed: 10/25/2023] Open
Abstract
Background Early neurological deterioration after endovascular thrombectomy (EVT) is associated with poor prognosis. National Institutes of Health Stroke Scale (NIHSS) score measured at 24 h after EVT may be a better outcome predictor than other methods that focus on changes in NIHSS. Nevertheless, clinical fluctuations in ischemic stroke patients during the immediate phase after symptoms onset are well recognized. Therefore, a delayed NIHSS evaluation may improve prognostic accuracy. We evaluate the 7-day NIHSS in predicting long-term patient outcomes after EVT. Methods This was a multi-center retrospective cohort study of 300 consecutive ischemic stroke patients with large vessel occlusion who underwent EVT at three-stroke centers in China from August 2018 to March 2022. NIHSS was recorded on admission, pre-EVT, 24 h, and 7 days after EVT. Results A total of 236 eligible patients were subdivided into two groups: 7-day NIHSS ≤6 and NIHSS >6 post-EVT. 88.29% achieved a favorable outcome (modified Rankin Scale 0-2) in the NIHSS ≤6 group compared to 15.20% in the NIHSS >6 group at 90 days, and an improved favorable outcome in the former group was observed after adjusting for potential confounding factors (adjusted odds ratio 39.7, 95% confidence interval, 17.5-89.7, p < 0.001). Conclusion The 7-day NIHSS score may be a reliable predictor of 90-day stroke patient outcome after EVT.
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Affiliation(s)
- Yuzheng Lai
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Foshan, Guangdong, China
- Nanhai District Hospital of Traditional Chinese Medicine of Foshan City, Foshan, 528000, Guangdong, China
| | - Eric Jou
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
| | - Thanh N. Nguyen
- Department of Neurology, Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Jamie Sin Ying Ho
- Department of Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Francesco Diana
- Department of Neuroradiology, A.O.U. San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, Salerno, Italy
| | - Adam A. Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jianfeng He
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Foshan, Guangdong, China
- Nanhai District Hospital of Traditional Chinese Medicine of Foshan City, Foshan, 528000, Guangdong, China
| | - Wenshan Yan
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Foshan, Guangdong, China
- Nanhai District Hospital of Traditional Chinese Medicine of Foshan City, Foshan, 528000, Guangdong, China
| | - Yiying Chen
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Foshan, Guangdong, China
- Nanhai District Hospital of Traditional Chinese Medicine of Foshan City, Foshan, 528000, Guangdong, China
| | - Zile Yan
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital, Foshan, 528100, Guangdong, China
| | - Hao Sun
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Foshan, Guangdong, China
- Nanhai District Hospital of Traditional Chinese Medicine of Foshan City, Foshan, 528000, Guangdong, China
| | - Leonard L. Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yimin Chen
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital, Foshan, 528100, Guangdong, China
- Department of Neurology, Neuro International Collaboration (NIC), Foshan, China
| | - Sijie Zhou
- Department of Surgery of Cerebrovascular Diseases, First People’s Hospital of Foshan, Foshan, 528000, Guangdong, China
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14
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Mistry EA, Nguyen TN. Blood pressure goals after mechanical thrombectomy: a moving target. Lancet 2022; 400:1558-1559. [PMID: 36341751 DOI: 10.1016/s0140-6736(22)01987-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Eva A Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA.
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery and Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
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15
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Xu C, Jin T, Chen Z, Zhang Z, Zhang K, Mao H, Ye S, Geng Y, Shi Z. Increased blood pressure variability during general anaesthesia is associated with worse outcomes after mechanical thrombectomy: a prospective observational cohort study. BMJ Open 2022; 12:e059108. [PMID: 36198453 PMCID: PMC9535158 DOI: 10.1136/bmjopen-2021-059108] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Optimal periprocedural blood pressure (BP) management during mechanical thrombectomy (MT) for acute ischaemic stroke is still controversial. The aim of this study was to investigate the association between intraprocedural BP variability (BPV) and outcomes in patients with large vessel occlusion (LVO) following MT with general anaesthesia. DESIGN A prospective observational cohort study. SETTING This study was conducted in a single tertiary hospital of Hangzhou in Zhejiang province. PARTICIPANTS A total of 141 patients with LVO treated with MT were finally included between January 2018 and September 2020. MAIN OUTCOME MEASURES Intraprocedural BP was recorded every 5 min throughout the procedure. BPV was measured as SD, coefficient of variation (CV), max-min (RANGE) and successive variation. Haemorrhagic transformation was assessed on 24-hour CT images according to European Cooperative Acute Stroke Study III trial. Poor functional outcome was defined as 90-day modified Rankin Scale score 3-6. Binary logistic regression analysis was used to investigate the association of BPV parameters with the incidence of parenchymal haemorrhage (PH) and poor functional outcome. RESULTS After controlling for age, female, history of smoking, hypertension and atrial fibrillation, baseline National Institutes of Health Stroke Scale, baseline systolic BP (SBP), baseline Alberta Stroke Program Early CT Score, bridging thrombolysis and times of retrieval attempts, the results demonstrated that intraprocedural SBPRANGE (OR 1.029; 95% CI 1.003 to 1.055; p=0.027), SBPSD (OR 1.135; 95% CI 1.023 to 1.259; p=0.017) and SBPCV (OR 1.189; 95% CI 1.053 to 1.342; p=0.005) were independently associated with poor functional outcome. However, the independent association between intraprocedural BPV and PH at 24 hours has not been established in this study. CONCLUSIONS Increased intraprocedural BPV was more likely to have poor functional outcome in patients with LVO following MT with general anaesthesia. This finding indicates that special precautions should be taken to minimise BP fluctuation during procedure.
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Affiliation(s)
- Chao Xu
- Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Tianyu Jin
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhicai Chen
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Zheyu Zhang
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Kemeng Zhang
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Hui Mao
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Sasa Ye
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Zongjie Shi
- Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
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16
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Association of 24-hour blood pressure parameters post-thrombectomy with functional outcomes according to collateral status. J Neurol Sci 2022; 441:120369. [DOI: 10.1016/j.jns.2022.120369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/07/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022]
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17
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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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18
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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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19
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Challenges in the hemodynamic management of acute nontraumatic neurological injuries. Curr Opin Crit Care 2022; 28:138-144. [PMID: 35102071 DOI: 10.1097/mcc.0000000000000925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To appraise the evidence from the literature and suggest an integrated hemodynamic approach of early and delayed phases of acute ischemic stroke (AIS), subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH). RECENT FINDINGS In AIS, the research aims to evaluate the optimal pressure control before, during and after the revascularization, to optimize the perfusion in the ischemic areas, minimizing the risk of hemorrhage or secondary damage to already infarcted areas. In the early phase of SAH, systemic pressure should be controlled to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure. The late phase aims to minimize the risk of cerebral vasospasm by adapting systemic pressure and volemia to cerebral and systemic physiological hemodynamic targets. In the mild-to-moderate ICH, achieving SAP of less than 140 mmHg and greater than 110 mmHg may be considered as a beneficial target. Caution should be considered in lowering intensively SAP in severe ICH. SUMMARY In nontraumatic brain injuries, the hemodynamic management is strictly related to fluctuating physiology of these diseases, needing a strict control of pressure and flow variable to ensure both cerebral and systemic homeostasis.
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20
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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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21
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Anadani M, Maïer B, Escalard S, Labreuche J, de Havenon A, Sabben C, Lapergue B, Gory B, Richard S, Sibon I, Desilles JP, Blanc R, Piotin M, Mazighi M. Magnitude of Blood Pressure Change After Endovascular Therapy and Outcomes: Insight From the BP-TARGET Trial. Stroke 2022; 53:719-727. [PMID: 35109685 DOI: 10.1161/strokeaha.121.036701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To assess the association between systolic blood pressure change (ΔSBP) at different time intervals after successful reperfusion with radiographic and clinical outcomes. METHODS This is a post hoc analysis of the BP-TARGET multicenter trial (Blood Pressure Target in Acute Stroke to Reduce Hemorrhage After Endovascular Therapy). ΔSBP was defined as end of procedure SBP minus mean SBP at different time intervals (15-60 minutes, 1-6 hours, and 6-24 hours postprocedure). The primary outcome was the poor functional outcome (90-day modified Rankin Scale score 3-6). RESULTS We included a total of 267 patients (130 in the intensive treatment group). Compared with patients with favorable outcome, patients with poor outcome had lower ΔSBP (less SBP reduction) at all times intervals. After adjusting for potential confounders including baseline SBP, both ΔSBP15-60M and ΔSBP6-24H were associated with lower odds of poor outcome (adjusted odds ratio per 5 mm Hg SBP reduction, 0.89 [95% CI, 0.81-0.99], and adjusted odds ratio 0.82 [95% CI, 0.73-0.92], respectively). Concerning safety outcomes, patients with intraparenchymal hemorrhage had lower ΔSBP at all time intervals. ΔSBP15-60M was associated with lower odds of any intraparenchymal hemorrhage (adjusted odds ratio per 5 mm Hg SBP reduction 0.91 [95% CI, 0.83-0.99]). Conversely, ΔSBP was not associated with mortality or neurological deterioration at any time interval. CONCLUSIONS After successful reperfusion, ΔSBP had a linear relationship with poor outcome and the risk of poor outcome was higher with less reduction from the baseline SBP. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03160677.
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Affiliation(s)
- Mohammad Anadani
- Department of Neurology, Washington University, St Louis, MO (M.A.).,Department of Neurosurgery, Medical University of South Carolina, Charleston (M.A.)
| | - Benjamin Maïer
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.).,University of Paris, France (B.M., J.-P.D., M.M.).,FHU Neurovasc, Paris, France (B.M., J.-P.D., R.B., M.P., M.M.)
| | - Simon Escalard
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.)
| | - Julien Labreuche
- University of Lille, CHU Lille, ULR 2694-METRICS: Évaluation des technologies de santé et des pratiques médicales, France (J.L.).,CHU Lille, Department of Biostatistics, France (J.L.)
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City (A.d.H.)
| | | | - Bertrand Lapergue
- Division of Neurology, Department of Neurology, Stroke Centre, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France (B.L.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Nancy, France (B.G.).,Université de Lorraine, IADI, INSERM U1254, Nancy, France (B.G.)
| | | | | | - Jean-Philippe Desilles
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.).,University of Paris, France (B.M., J.-P.D., M.M.).,FHU Neurovasc, Paris, France (B.M., J.-P.D., R.B., M.P., M.M.)
| | - Raphael Blanc
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.).,FHU Neurovasc, Paris, France (B.M., J.-P.D., R.B., M.P., M.M.)
| | - Michel Piotin
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.).,FHU Neurovasc, Paris, France (B.M., J.-P.D., R.B., M.P., M.M.)
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France (B.M., S.E., J.-P.D., R.B., M.P., M.M.).,University of Paris, France (B.M., J.-P.D., M.M.).,FHU Neurovasc, Paris, France (B.M., J.-P.D., R.B., M.P., M.M.)
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22
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Robichon E, Maïer B, Mazighi M. Endovascular therapy for acute ischemic stroke: The importance of blood pressure control, sedation modality and anti-thrombotic management to improve functional outcomes. Rev Neurol (Paris) 2022; 178:175-184. [DOI: 10.1016/j.neurol.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 08/08/2021] [Accepted: 09/27/2021] [Indexed: 01/04/2023]
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23
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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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24
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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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25
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Feldman MJ, Roth S, Fusco MR, Mehta T, Arora N, Siegler JE, Schrag M, Mittal S, Kirshner H, Mistry AM, Yaghi S, Chitale RV, Khatri P, Mistry EA. Association of asymptomatic hemorrhage after endovascular stroke treatment with outcomes. J Neurointerv Surg 2021; 13:1095-1098. [PMID: 33558440 DOI: 10.1136/neurintsurg-2020-017123] [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] [Received: 11/15/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) occurs in ~20%-30% of stroke patients undergoing endovascular therapy (EVT). However, there is conflicting evidence regarding the effect of asymptomatic ICH (aICH) on post-EVT outcomes. We sought to evaluate the effect of aICH on immediate and 90-day post-EVT neurological outcomes. METHODS In this post-hoc analysis of the multicenter, prospective Blood Pressure after Endovascular Therapy (BEST) study we identified subjects with ICH following EVT. This population was divided into no ICH, aICH, and symptomatic ICH (sICH). Associations with 90-day modified Rankin Scale (mRS) dichotomized by functional independence (0-2 vs 3-6) and early neurological recovery (ENR) were determined using univariate/multivariate logistic regression models. RESULTS Of 485 patients enrolled in BEST, 446 had 90-day follow-up data available. 92 (20.6%) developed aICH, and 18 (4%) developed sICH. Compared with those without ICH, aICH was not associated with worse 90-day outcome or lower ENR (OR 0.84 [0.53-1.35], P=0.55, aOR 0.84 [0.48-1.44], P=0.53 for 90-day mRS 0-2; OR 0.77 [0.48-1.23], P=0.34, aOR 0.72 [0.43-1.22] for ENR). aICH was not associated with 90-day outcome or ENR in patients with mTICI ≥2 b (OR 0.78 [0.48-1.26], P=0.33 for 90-day mRS 0-2; OR 0.89 [0.69-1.12], P=0.15 for ENR). A higher proportion of patients with aICH had mTICI ≥2 b than those without ICH (97%vs 87%, P=0.01). CONCLUSIONS aICH was not associated with worse outcomes in patients with large-vessel stroke treated with EVT. aICH was more frequent in patients with successful recanalization. Further validation of our findings in large cohort studies of EVT-treated patients is warranted.
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Affiliation(s)
- Michael J Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Steven Roth
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew R Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tapan Mehta
- Interventional Neuroradiology and Neurology, Hartford Hospital, Hartford, Connecticut, USA
| | - Niraj Arora
- Neurology, University of Missouri, Columbia, Missouri, USA
| | - James E Siegler
- Cooper Neurologic Institute, Cooper University Health Care, Camden, New Jersey, USA
| | - Matthew Schrag
- Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shilpi Mittal
- Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Howard Kirshner
- Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Akshitkumar M Mistry
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shadi Yaghi
- Neurology, New York University Medical Center, New York, New York, USA
| | - Rohan V Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pooja Khatri
- Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Eva A Mistry
- Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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26
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Hong JM, Kim DS, Kim M. Hemorrhagic Transformation After Ischemic Stroke: Mechanisms and Management. Front Neurol 2021; 12:703258. [PMID: 34917010 PMCID: PMC8669478 DOI: 10.3389/fneur.2021.703258] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/21/2021] [Indexed: 01/01/2023] Open
Abstract
Symptomatic hemorrhagic transformation (HT) is one of the complications most likely to lead to death in patients with acute ischemic stroke. HT after acute ischemic stroke is diagnosed when certain areas of cerebral infarction appear as cerebral hemorrhage on radiological images. Its mechanisms are usually explained by disruption of the blood-brain barrier and reperfusion injury that causes leakage of peripheral blood cells. In ischemic infarction, HT may be a natural progression of acute ischemic stroke and can be facilitated or enhanced by reperfusion therapy. Therefore, to balance risks and benefits, HT occurrence in acute stroke settings is an important factor to be considered by physicians to determine whether recanalization therapy should be performed. This review aims to illustrate the pathophysiological mechanisms of HT, outline most HT-related factors after reperfusion therapy, and describe prevention strategies for the occurrence and enlargement of HT, such as blood pressure control. Finally, we propose a promising therapeutic approach based on biological research studies that would help clinicians treat such catastrophic complications.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Da Sol Kim
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Min Kim
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
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27
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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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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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29
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Katsanos AH, Malhotra K, Ahmed N, Seitidis G, Mistry EA, Mavridis D, Kim JT, Veroniki A, Maier I, Matusevicius M, Khatri P, Anadani M, Goyal N, Arthur AS, Sarraj A, Yaghi S, Shoamanesh A, Catanese L, Kantzanou M, Psaltopoulou T, Rentzos A, Psychogios M, Van Adel B, Spiotta AM, Sandset EC, de Havenon A, Alexandrov AV, Petersen NH, Tsivgoulis G. Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis. Neurology 2021; 98:e291-e301. [PMID: 34772799 DOI: 10.1212/wnl.0000000000013049] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). METHODS A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model. RESULTS A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission: 16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT. CONCLUSION Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada .,Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Georgios Seitidis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Paris Descartes University, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Argie Veroniki
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Ilko Maier
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Marius Matusevicius
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mohammad Anadani
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Amrou Sarraj
- Department of Neurology, UT Houston, Houston, Texas, USA
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Luciana Catanese
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Maria Kantzanou
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rentzos
- Diagnostic and Interventional Neuroradiology, Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marios Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Brian Van Adel
- Division of Neurology, Neurosurgery, and Diagnostic Imaging, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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30
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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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31
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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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32
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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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33
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Affiliation(s)
- Ruchira M Jha
- Departments of Neurology, Neurobiology, Neurosurgery, St Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ (R.M.J.)
| | - Kevin N Sheth
- Departments of Neurology, Neurosurgery, Clinical and Translational Research, Yale School of Medicine, New Haven, CT (K.N.S.)
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34
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [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: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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35
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Mistry EA, Yeatts S, de Havenon A, Mehta T, Arora N, De Los Rios La Rosa F, Starosciak AK, Siegler JE, Mistry AM, Yaghi S, Khatri P. Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change. Stroke 2021; 52:2547-2553. [PMID: 34000830 DOI: 10.1161/strokeaha.120.032487] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The National Institutes of Health Stroke Scale (NIHSS) measured at an early time point is an appealing surrogate marker for long-term functional outcome of stroke patients treated with endovascular therapy. However, definitions and analytical methods for an early NIHSS-based outcome measure that optimize power and precision in clinical studies are not well-established. METHODS In this post-hoc analysis of our prospective observational study that enrolled endovascular therapy-treated patients at 12 comprehensive stroke centers across the US, we compared the ability of 24-hour NIHSS, ΔNIHSS (baseline minus 24-hour NIHSS), and percentage change (NIHSS×100/baseline NIHSS), analyzed as continuous and dichotomous measures, to predict 90-day modified Rankin Scale (mRS) using logistic regression (adjusted for age, baseline NIHSS, glucose, hypertension, Alberta Stroke Program Early CT Score, time to recanalization, recanalization status, and intravenous thrombolysis) and Spearman ρ. RESULTS Of 485 patients in the BEST (Blood Pressure After Endovascular Stroke Therapy) cohort, 446 (92%) with 90-day follow-up data were included. An absolute 24-hour NIHSS, adjusted for baseline in multivariable modeling, had the highest predictive power of all definitions evaluated (aR2 0.368 and adjusted odds ratio 0.79 [0.75-0.84], P<0.001 for mRS score 0-2; aR2 0.444 and adjusted odds ratio 0.84 [0.8-0.86] for ordinal mRS). For predicting mRS score of 0-2 with a cut point, the second most efficient approach, the optimal threshold for 24-hour NIHSS score was ≤7 (sensitivity 80.1%, specificity 80.4%; adjusted odds ratio 12.5 [7.14-20], P<0.001), followed by percent change in NIHSS (sensitivity 79%, specificity 58.5%; adjusted odds ratio 4.55 [2.85-7.69], P<0.001). CONCLUSIONS Twenty-four-hour NIHSS, adjusted for baseline, was the strongest predictor of both dichotomous and ordinal 90-day mRS outcomes for endovascular therapy-treated patients. A dichotomous 24-hour NIHSS score of ≤7 was the second-best predictor. Although ΔNIHSS, continuous and dichotomized at ≥4, predicted 90-day outcomes, absolute 24-hour NIHSS definitions performed better.
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Affiliation(s)
- Eva A Mistry
- Department of Neurology (E.A.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Sharon Yeatts
- Public Health Sciences, Medical University of South Carolina, Charleston (S.Y.)
| | | | - Tapan Mehta
- Ayer Neuroscience Institute, Hartford HealthCare, CT (T.M.)
| | - Niraj Arora
- Department of Neurology, University of Missouri, Columbia (N.A.)
| | | | - Amy K Starosciak
- Baptist Health Neuroscience Center, Miami, FL (F.D.L.R.L.R., A.K.S.)
| | - James E Siegler
- Department of Neurology, Cooper University Hospital, Camden, NJ (J.E.S.)
| | - Akshitkumar M Mistry
- Department of Neurosurgery (A.M.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Shadi Yaghi
- Department of Neurology, New York Langone Health (S.Y.)
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K.)
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36
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Anadani M, de Havenon A, Mistry E, Anderson CS. Blood Pressure Management After Endovascular Therapy: An Ongoing Debate. Stroke 2021; 52:e263-e265. [PMID: 34000832 DOI: 10.1161/strokeaha.121.034995] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Mohammad Anadani
- Department of Neurology, Washington University in St. Louis School of Medicine, MO (M.A.)
| | | | - Eva Mistry
- Vanderbilt University Medical Center, TN (E.M.)
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.S.A.)
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37
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Anadani M, Matusevicius M, Tsivgoulis G, Peeters A, Nunes AP, Mancuso M, Roffe C, de Havenon A, Ahmed N. Magnitude of blood pressure change and clinical outcomes after thrombectomy in stroke caused by large artery occlusion. Eur J Neurol 2021; 28:1922-1930. [PMID: 33682232 DOI: 10.1111/ene.14807] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Extremes of both high and low systolic blood pressure (SBP) after mechanical thrombectomy (MT) in large artery occlusion stroke are known predictors of unfavorable outcome. However, the effect of SBP change (∆SBP) during the first 24 h on thrombectomy outcomes remains unclear. We aimed to investigate the association between ∆SBP at different time intervals and thrombectomy outcomes. METHODS We analyzed MT-treated patients registered in the SITS International Stroke Thrombectomy Registry from January 1, 2014 to September 3, 2019. Primary outcome was 3-month unfavorable outcome (modified Rankin scale scores 3-6). We defined ∆SBP as the mean SBP of a given time interval after MT (0-2, 2-4, 4-12, 12-24 h) minus admission SBP. Multivariable mixed logistic regression models were used to adjust for known confounders and center as random effect. Subgroup analyses were included to contrast specific subpopulations. Restricted cubic splines were used to model the associations. RESULTS The study population consisted of 5835 patients (mean age 70 years, 51% male, median NIHSS 16). Mean ∆SBP was -12.3, -15.7, -17.2, and -16.9 mmHg for the time intervals 0-2, 2-4, 4-12 h, and 12-24 h, respectively. Higher ∆SBP was associated with unfavorable outcome at 0-2 h (odds ratio 1.065, 95% confidence interval 1.014-1.118), 2-4 h (1.140, 1.081-1.203), 4-12 h (1.145, 1.087-1.203), and 12-24 h (1.145, 1.089-1.203), for every increase of 10 mmHg. Restricted cubic spline models suggested that increasing ∆SBP was associated with unfavorable outcome, with higher values showing increased risk of unfavorable outcome. CONCLUSION SBP increase after thrombectomy in large artery occlusion stroke is associated with poor functional outcome.
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Affiliation(s)
- Mohammad Anadani
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Marius Matusevicius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Ana Paiva Nunes
- Stroke Unit Centro Hospitalar Universitário de Lisboa Central - Hospital São José, Lisbon, Portugal
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Christine Roffe
- Stroke Research in Stoke, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurovascular Disease, Karolinska University Hospital, Stockholm, Sweden
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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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Huang X, Guo H, Yuan L, Cai Q, Zhang M, Zhang Y, Zhu W, Li Z, Yang Q, Zhou Z, Sun W, Liu X. Blood pressure variability and outcomes after mechanical thrombectomy based on the recanalization and collateral status. Ther Adv Neurol Disord 2021; 14:1756286421997383. [PMID: 33747130 PMCID: PMC7940733 DOI: 10.1177/1756286421997383] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/29/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Blood pressure (BP), recanalization status, and collateral circulation are important factors for cerebral autoregulation after stroke. We aimed to investigate the association of various BP variability (BPV) parameters with clinical outcomes after mechanical thrombectomy (MT) according to recanalization and collateral status. METHODS We included 502 consecutive patients who underwent MT due to anterior circulation large vessel occlusion stroke at three comprehensive stroke centers. BPV parameters were standard deviation (SD), maximum/minimum BP, coefficient of variation (CV) and successive variation (SV). The clinical outcomes included 90-day functional outcome assessed by modified Rankin Scale score and symptomatic intracranial hemorrhage (sICH). RESULTS Among the included patients, 219 (43.6%) achieved good functional outcomes and 59 (11.8%) developed sICH. After adjusting for confounders, higher systolic BP (SBP) variability [CV (odds ratio (OR), 1.089, p = 0.035), SV (OR, 1.082, p = 0.004). and SD (OR, 1.074, p = 0.027)] was associated with a lower likelihood of a favorable outcome. In addition, higher SBP [CV (OR, 1.156, p = 0.001) and SD (OR, 1.118, p = 0.001)] were significantly associated with increased odds of sICH. Moreover, the relationship between BPV and the outcomes depended on recanalization status. However, regardless of collateral status, a higher BPV after MT was associated with worse outcomes. CONCLUSIONS Higher SBP SD and CV during the first 24 h after MT was a powerful predictor of worse clinical outcomes, regardless of the collateral status. However, the effects of BPV on outcomes were more substantial among patients with successful reperfusion.
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Affiliation(s)
- Xianjun Huang
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, Jiangsu Province, China
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, China
| | - Hongquan Guo
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, Jiangsu Province, China
| | - Lili Yuan
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, China
| | - Qiankun Cai
- Department of Neurology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Min Zhang
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yi Zhang
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, Jiangsu Province, China
| | - Wusheng Zhu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Zibao Li
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, China
| | - Qian Yang
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, China
| | - Wen Sun
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, 305# East Zhongshan Road, Nanjing, Jiangsu Province 210002, China
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40
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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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41
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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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42
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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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43
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Gigliotti MJ, Padmanaban V, Richardson A, Simon SD, Church EW, Cockroft KM. Effect of Blood Pressure Management Strategies on Outcomes in Patients with Acute Ischemic Stroke After Successful Mechanical Thrombectomy. World Neurosurg 2021; 148:e635-e642. [PMID: 33497823 DOI: 10.1016/j.wneu.2021.01.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Variability, with no general consensus, exists in how patients' blood pressure should be managed after successful mechanical thrombectomy (MT) for large vessel ischemic stroke. We examined whether exceeding the systolic blood pressure (SBP) targets in patients during the first 24 hours after successful MT led to worse outcomes. METHODS We retrospectively studied a consecutive sample of adult patients who had undergone MT. We collected SBP data for the first 24 hours after MT and categorized the patients into 3 groups according to cases of the SBP exceeding 140, 160, or 180 mm Hg. The primary and secondary outcomes were the modified Rankin scale score at discharge and 90 days of follow-up, the incidence of symptomatic intracranial hemorrhage, malignant cerebral edema, and hemicraniectomy, mortality within 90 days, and discharge disposition. RESULTS A total of 117 patients were included (mean age, 65 ± 13.12 years; 53% female). The occurrence of ≥1 instance of SBP ≥180 mm Hg was significantly associated with poor functional outcomes at discharge (adjusted odds ratio [OR], 5.83; 95% confidence interval [CI], 1.41-32.9; P = 0.025) but not at 90 days of follow-up. The occurrence of SBP ≥160 mm Hg resulted in an independently increased odds of malignant cerebral edema (adjusted OR, 17.07; 95% CI, 2.56-174.4; P = 0.01), with a trend toward increased odds of symptomatic intracranial hemorrhage (adjusted OR, 4.42; 95% CI, 1.03-21.2; P = 0.0503). CONCLUSIONS These results suggest that individual instances of SBP elevation alone after successful MT, rather than a necessarily prolonged increased blood pressure as reflected by the mean or median SBP values, can significantly affect the clinical outcomes after successful MT.
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Affiliation(s)
- Michael J Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Varun Padmanaban
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Alicia Richardson
- Penn State Hershey Comprehensive Stroke Center, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Scott D Simon
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Ephraim W Church
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Penn State Hershey Comprehensive Stroke Center, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
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44
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Impact of the Perioperative Blood Pressure on Clinical Outcome after Thrombectomy in Acute Basilar Artery Occlusion. J Stroke Cerebrovasc Dis 2021; 30:105590. [PMID: 33583512 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 02/05/2023] Open
Abstract
AIM Optimal blood pressure (BP) management in vertebrobasilar circulation stroke patients undergoing thrombectomy remains undetermined. We aimed to evaluate the impact of perioperative BP on clinical outcome after MT in acute basilar artery occlusion (BAO) patients. METHODS We retrospectively analyzed all consecutive patients hospitalized with acute basilar artery occlusion administered endovascular treatment within 24 h from January 2012 to July 2018 in Beijing Tiantan Hospital. BP was measured at regular intervals during the first 24 h after stroke onset, during and after thrombectomy. The clinical outcomes assessed at 3-month follow up were functional independence (mRS score of 0-2) and mortality (mRS score of 6). RESULTS Of the 187 treated patients, 157 were male; patient ages were 60±10 years. The median NIHSS on admission was 22. Totally in 179 patients had complete BP level assessment. In these individuals, univariate analysis revealed significant associations of postoperative Max SBP and Max MAP with mortality (all P < 0.05). Multivariate regression analysis also demonstrated that postoperative Max SBP (OR=0.964, 95% CI 0.941 to 0.987, P < 0.003) and Max MAP (OR=0.942, 95% CI 0.907 to 0.979, P < 0.002) were independent predictors of mortality. CONCLUSIONS In acute BAO patients administered thrombectomy, Max SBP between 120 and 160 mmHg may be associated with better outcome, with a trend of reduced risk of mortality.
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45
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Jafari M, Desai A, Damani R. Blood pressure management after mechanical thrombectomy in stroke patients. J Neurol Sci 2020; 418:117140. [PMID: 32961389 DOI: 10.1016/j.jns.2020.117140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/15/2022]
Abstract
Endovascular treatment of acute ischemic stroke (AIS) and mechanical thrombectomy (MT) is proven as a safe and effective novel treatment for emergent large vessel occlusion in the anterior cerebral circulation. However, there are still many unanswered questions on peri and post-procedural management including blood pressure (BP) control. The current guidelines recommend maintaining BP <180/105 mmHg in the first 24 h after MT. However, recent studies suggest that maintaining BP levels at lower levels in the first 24 h after successful revascularization have been associated with favorable functional outcome, reduced mortality rate, and hemorrhagic complications. Not only absolute BP but also its variation in the first 24 h after MT have been associated with neurological outcomes. Evidence on the effect of BP variability (BPV) after MT in AIS even though limited, it does indicate the association of the higher BPV in the first 24 h after MT and poor functional outcomes in AIS. In this review, we will discuss the current literature on BP management in the first 24 h after MT and the impact of BPV in the first 24 h after MT.
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Affiliation(s)
- Mostafa Jafari
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Aaron Desai
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Rahul Damani
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
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46
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Maïer B, Delvoye F, Labreuche J, Escalard S, Desilles JP, Redjem H, Hébert S, Smajda S, Ciccio G, Lapergue B, Blanc R, Piotin M, Mazighi M. Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review. Front Neurol 2020; 11:573382. [PMID: 33193021 PMCID: PMC7659685 DOI: 10.3389/fneur.2020.573382] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: Optimal blood pressure (BP) targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) still need to be assessed, especially according to the recanalization status. Facing the lack of randomized controlled trials addressing this question, we performed a systematic review of studies assessing the post-EVT BP impact on functional outcome and symptomatic intracranial hemorrhage (sICH). Methods: Studies published after January 1, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work. Results: Five studies were included in the present analysis. Despite a significant heterogeneity among studies which precluded a meta-analysis, systolic BP (SBP) was the most frequently used parameter to describe BP. BP variability (standard deviation, successive variability) after EVT was associated with worse functional outcome, especially in studies without specific BP targets after successful EVT. Lower BP values after successful EVT were associated with lower odds of sICH. Four studies evaluated the post-EVT BP impact on recanalized patients solely, with only one specifically addressing the impact of a TICI 2B vs. 2C. Interestingly, SBP reduction was inversely associated with worse outcomes in TICI 3 patients but not in TICI 2B patients, pointing to the potential value of BP management according to the exact TICI. Conclusions: BP post-EVT seems to be associated with worse functional outcomes and sICH. However, given the important heterogeneity depicted among the included studies, no decisive conclusion can be made from this systematic review, thus underlying the urgent need of randomized controlled trials evaluating this question.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.,Université de Paris, Paris, France
| | - François Delvoye
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Julien Labreuche
- University Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Simon Escalard
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.,Université de Paris, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Hocine Redjem
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Solène Hébert
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Stanislas Smajda
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Gabriele Ciccio
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | | | - Raphaël Blanc
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.,Université de Paris, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France.,FHU Neurovasc, Paris, France
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47
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Anadani M, de Havenon A, Yaghi S, Mehta T, Arora N, Starosciak AK, De Los Rios La Rosa F, Siegler J, Mistry AM, Chitale R, Spiotta AM, Tsivgoulis G, Khatri P, Mistry EA. Blood pressure reduction and outcome after endovascular therapy: a secondary analysis of the BEST study. J Neurointerv Surg 2020; 13:698-702. [PMID: 32883780 DOI: 10.1136/neurintsurg-2020-016494] [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] [Received: 06/11/2020] [Revised: 07/28/2020] [Accepted: 08/01/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Elevated systolic blood pressure (SBP) in the acute phase after endovascular therapy (EVT) is associated with worse outcome. However, the association between systolic blood pressure reduction (SBPr) and the outcome of EVT is not well understood. OBJECTIVE To determine the association between SBPr and clinical outcomes after EVT in a prospective multicenter cohort. METHODS A post hoc analysis of the Blood Pressure after Endovascular Stroke Therapy (BEST) prospective observational cohort study was carried out. SBPr was defined as the absolute difference between admission SBP and mean SBP in the first 24 hours after EVT. Logistic regression was used to assess the association between SBPr and poor functional outcome (modified Rankin Scale score 3-6) at 90 days. RESULTS A total of 259/433 (58.5%) patients had poor outcome. SBPr was higher in the poor outcome group than in the good outcome group (26.6±27.4 vs 19.0±22.3 mm Hg; p<0.001). However, in adjusted models, SBPr was not independently associated with poor outcome (OR=1.00 per 1 mm Hg increase, 95% CI 0.99 to 1.01) or death (OR=0.9 per 1 mm Hg increase; 95% CI 0.98 to 1.00). No association remained when SBPr was divided into tertiles. Subgroup analyses based on history of hypertension, revascularization status, and antihypertensive treatment yielded similar results. CONCLUSION The reduction in baseline SBP following EVT was not associated with poor functional outcomes. Most of the cohort (88%) achieved successful recanalization, and therefore, these results mainly apply to patients with successful recanalization.
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Affiliation(s)
- Mohammad Anadani
- Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.,Department of Neurology, Medical University of South Carolina - College of Medicine, Charleston, South Carolina, USA
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, Brooklyn, New York, USA
| | - Tapan Mehta
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Niraj Arora
- Department of Neurology, University of Missouri, Columbia, South Carolina, USA
| | - Amy Kathryn Starosciak
- Neuroscience Center - 2 Clarke, Baptist Hospital, Miami, Florida, USA.,Center for Research, Baptist Health South Florida, Coral Gables, Florida, USA
| | | | - James Siegler
- Department of Neurology, Cooper University Health, Camden, New Jersey, USA
| | - Akshitkumar M Mistry
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rohan Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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48
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Das S, John KD, Bokka SK, Remmel K, Akça O. Blood Pressure Management Following Large Vessel Occlusion Strokes: A Narrative Review. Balkan Med J 2020; 37:253-259. [PMID: 32475092 PMCID: PMC7424178 DOI: 10.4274/balkanmedj.galenos.2020.2020.4.196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Stroke is one of the leading causes of morbidity and mortality worldwide. Intravenous tissue plasminogen activator and mechanical thrombectomy comprise the two major treatments for acute ischemic stroke. Tissue plasminogen activator has been used for more than two decades and guidelines for hemodynamic management following tissue plasminogen activator administration are well established. However, mechanical thrombectomy is a relatively newer therapy and there is a paucity of evidence regarding hemodynamic management following large vessel occlusion strokes. The important tenets guiding the pathophysiology of large vessel occlusion strokes include understanding of cerebral autoregulation, collateral circulation, and blood pressure variability. In this narrative review, we discuss the current American Heart Association-American Stroke Association guidelines for the early management of acute ischemic stroke during different phases of the illness, encountered at different sections of a hospital including the emergency room, the neuro-interventional suite, and the intensive care unit. There is emerging evidence with regard to post-recanalization blood pressure management following large vessel occlusion strokes. Future research directions will include rea-ltime blood pressure variability assessments, identifying the extent of impaired autoregulation, and providing guidelines related to range and personalized blood pressure trajectories for patients following large vessel occlusion strokes.
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Affiliation(s)
- Saurav Das
- Department of Neurology, Louisville University School of Medicine, Louisville, Kentucky, USA
| | - Kevin Denny John
- University of Louisville, School of Medicine, Louisville, Kentucky, USA
| | - Satheesh Kumar Bokka
- Department of Neurology, Louisville University School of Medicine, Louisville, Kentucky, USA
| | - Kerri Remmel
- Department of Anesthesiology and Perioperative Medicine, Stroke ICU, Louisville University Hospital, Louisville, Kentucky, USA
- Comprehensive Stroke Clinical Research Program, University of Louisville, Louisville, Kentucky, USA
| | - Ozan Akça
- Department of Anesthesiology and Perioperative Medicine, Stroke ICU, Louisville University Hospital, Louisville, Kentucky, USA
- Comprehensive Stroke Clinical Research Program, University of Louisville, Louisville, Kentucky, USA
- * Address for Correspondence: Comprehensive Stroke Clinical Research Program, University of Louisville, Louisville, Kentucky, USA Phone: +90 502 852 58 51 E-mail:
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49
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Mazighi M, Labreuche J, Richard S, Gory B, Lapergue B, Sibon I, Berge J, Olivot JM, Reiner P, Houdart E, Broderick J, Duhammel A, Maier B, Yavchitz A, Salomon L, Obadia M, Blanc R, Savatovsky J, Piotin M. Blood Pressure Target in Acute Stroke to Reduce HemorrhaGe After Endovascular Therapy: The Randomized BP TARGET Study Protocol. Front Neurol 2020; 11:480. [PMID: 32636793 PMCID: PMC7316985 DOI: 10.3389/fneur.2020.00480] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/04/2020] [Indexed: 12/11/2022] Open
Abstract
Background: High systolic blood pressure (BP) is associated with an increased risk of intracranial hemorrhage (ICH) in patients undergoing reperfusion therapy. However, there are no data from randomized trials to guide BP management after reperfusion following endovascular therapy (EVT) for patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO). The objective is to evaluate if BP control with a target of 100-129 mmHg systolic BP ("tight" SBP control) can reduce ICH as compared to 130-185 mmHg ("usual" SBP control) in AIS participants after reperfusion by EVT. Methods: The BP TARGET trial is a multicenter, prospective, randomized, controlled, open-label, blinded endpoint clinical trial. AIS participants with LVO experiencing successful reperfusion are randomly assigned, in a 1:1 ratio, to have a "tight" SBP control (100-129 mmHg) or a conservative SBP control (130-185 mmHg) during the following 24-36 h. The primary outcome is the rate of ICH (either symptomatic or asymptomatic) on follow-up CT scan at 24-36 h. Secondary outcomes include the rate of the symptomatic ICH, the overall distribution of the modified Rankin Scale (mRS) at 90 days, favorable outcome (90-day mRs 0-2), infarct volume at follow-up CT scan at 24-36 h, change in National Institute of Health Stroke Scale at 24 h, and all-cause mortality at 90 days. Conclusion: This is the first randomized trial directly comparing the efficacy of different SBP targets after EVT reperfusion. This prospective trial aims to determine whether a "tight" SBP control after EVT reperfusion can reduce the risk of ICH.
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Affiliation(s)
- Mikael Mazighi
- Department of Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild Hospital, Paris, France.,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France.,Paris University, Paris, France.,DHU NeuroVasc, Paris, France
| | - Julien Labreuche
- University of Lille, CHU Lille, EA 2694, Santé Publique: Épidémiologie et Qualité des Soins, Lille, France
| | - Sebastien Richard
- Department of Neurology, Stroke Unit, University Hospital of Nancy, Nancy, France.,INSERM U1116, Nancy, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France.,INSERM U1254, Nancy, France
| | - Bertrand Lapergue
- Division of Neurology, Department of Neurology, Stroke Center, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France
| | - Igor Sibon
- Pôle des Neurosciences Cliniques, CHU Bordeaux, Bordeaux, France
| | - Jerome Berge
- Interventional and Diagnostic Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | | | - Peggy Reiner
- Department of Neurology, Lariboisière Hospital, Paris, France
| | - Emmanuel Houdart
- Department of Neuroradiology, Lariboisière Hospital, Paris, France
| | - Joseph Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Alain Duhammel
- University of Lille, CHU Lille, EA 2694, Santé Publique: Épidémiologie et Qualité des Soins, Lille, France
| | - Benjamin Maier
- Department of Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild Hospital, Paris, France
| | - Amélie Yavchitz
- Department of Clinical Research, Fondation Ophtalmologique Adolphe de Rothschild Hospital, Paris, France
| | - Laurence Salomon
- Department of Clinical Research, Fondation Ophtalmologique Adolphe de Rothschild Hospital, Paris, France
| | - Michael Obadia
- Stroke Unit, Fondation Ophtalmologique Adolphe de Rothschild Hospital, Paris, France
| | - Raphael Blanc
- Department of Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild Hospital, Paris, France.,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Julien Savatovsky
- Department of Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild Hospital, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild Hospital, Paris, France.,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
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50
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Syal A, Kalen B, Patra DP, Rahme RJ, Turcotte E, Bendok B. Blood Pressure Management After Embolectomy for Cerebral Large Vessel Occlusion: Toward Evidence-Based Guidelines. World Neurosurg 2020; 138:551-552. [PMID: 32544991 DOI: 10.1016/j.wneu.2020.01.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Arjun Syal
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Brian Kalen
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Devi P Patra
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Rudy J Rahme
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Evelyn Turcotte
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard Bendok
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
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