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Zompola C, Palaiodimou L, Voumvourakis K, Stefanis L, Katsanos AH, Sandset EC, Boviatsis E, Tsivgoulis G. Blood Pressure Variability in Acute Stroke: A Narrative Review. J Clin Med 2024; 13:1981. [PMID: 38610746 PMCID: PMC11012361 DOI: 10.3390/jcm13071981] [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: 03/12/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
The management of blood pressure variability (BPV) in acute stroke presents a complex challenge with profound implications for patient outcomes. This narrative review examines the role of BPV across various stages of acute stroke care, highlighting its impact on treatment strategies and prognostic considerations. In the prehospital setting, while guidelines lack specific recommendations for BP management, emerging evidence suggests a potential link between BPV and outcomes. Among ischaemic stroke patients who are ineligible for reperfusion therapies, BPV independently influences functional outcomes, emphasising the need for individualised approaches to BP control. During intravenous thrombolysis and endovascular therapy, the intricate interplay between BP levels, recanalisation status, and BPV is evident. Striking a balance between aggressive BP lowering and avoiding hypoperfusion-related complications is essential. Intracerebral haemorrhage management is further complicated by BPV, which emerges as a predictor of mortality and disability, necessitating nuanced BP management strategies. Finally, among patients with acute subarachnoid haemorrhage, increased BPV may be correlated with a rebleeding risk and worse outcomes, emphasizing the need for BPV monitoring in this population. Integration of BPV assessment into clinical practice and research protocols is crucial for refining treatment strategies that are tailored to individual patient needs. Future studies should explore novel interventions targeting BPV modulation to optimise stroke care outcomes.
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Affiliation(s)
- Christina Zompola
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Leonidas Stefanis
- First Department of Neurology, “Aeginition” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON L8L2X2, Canada
| | - Else C. Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, N-0424 Oslo, Norway
| | - Estathios Boviatsis
- Second Department of Neurosurgery, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
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Palaiodimou L, Joundi RA, Katsanos AH, Ahmed N, Kim JT, Goyal N, Maier IL, de Havenon A, Anadani M, Matusevicius M, Mistry EA, Khatri P, Arthur AS, Sarraj A, Yaghi S, Shoamanesh A, Catanese L, Psychogios MN, Malhotra K, Spiotta AM, Vassilopoulou S, Tsioufis K, Sandset EC, Alexandrov AV, Petersen N, Tsivgoulis G. Association between blood pressure variability and outcomes after endovascular thrombectomy for acute ischemic stroke: An individual patient data meta-analysis. Eur Stroke J 2024; 9:88-96. [PMID: 37921233 PMCID: PMC10916831 DOI: 10.1177/23969873231211157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/14/2023] [Indexed: 11/04/2023] Open
Abstract
INTRODUCTION Data on the association between blood pressure variability (BPV) after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) and outcomes are limited. We sought to identify whether BPV within the first 24 hours post EVT was associated with key stroke outcomes. METHODS We combined individual patient-data from five studies among AIS-patients who underwent EVT, that provided individual BP measurements after the end of the procedure. BPV was estimated as either systolic-BP (SBP) standard deviation (SD) or coefficient of variation (CV) over 24 h post-EVT. We used a logistic mixed-effects model to estimate the association [expressed as adjusted odds ratios (aOR)] between tertiles of BPV and outcomes of 90-day mortality, 90-day death or disability [modified Rankin Scale-score (mRS) > 2], 90-day functional impairment (⩾1-point increase across all mRS-scores), and symptomatic intracranial hemorrhage (sICH), adjusting for age, sex, stroke severity, co-morbidities, pretreatment with intravenous thrombolysis, successful recanalization, and mean SBP and diastolic-BP levels within the first 24 hours post EVT. RESULTS There were 2640 AIS-patients included in the analysis. The highest tertile of SBP-SD was associated with higher 90-day mortality (aOR:1.44;95% CI:1.08-1.92), 90-day death or disability (aOR:1.49;95% CI:1.18-1.89), and 90-day functional impairment (adjusted common OR:1.42;95% CI:1.18-1.72), but not with sICH (aOR:1.22;95% CI:0.76-1.98). Similarly, the highest tertile of SBP-CV was associated with higher 90-day mortality (aOR:1.33;95% CI:1.01-1.74), 90-day death or disability (aOR:1.50;95% CI:1.19-1.89), and 90-day functional impairment (adjusted common OR:1.38;95% CI:1.15-1.65), but not with sICH (aOR:1.33;95% CI:0.83-2.14). CONCLUSIONS BPV after EVT appears to be associated with higher mortality and disability, independently of mean BP levels within the first 24 h post EVT. BPV in the first 24 h may be a novel target to improve outcomes after EVT for AIS.
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Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Raed A Joundi
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Aristeidis H Katsanos
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ilko L Maier
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Mohammad Anadani
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Marius Matusevicius
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Amrou Sarraj
- Department of Neurology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY, USA
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Luciana Catanese
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Sofia Vassilopoulou
- First Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nils Petersen
- Department of Neurology, Yale University, New Haven, CT, 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, TN, USA
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Impact of leukoaraiosis or blood pressure on clinical outcome, mortality and symptomatic intracerebral hemorrhage after mechanical thrombectomy in acute ischemic stroke. Sci Rep 2022; 12:21750. [PMID: 36526650 PMCID: PMC9758212 DOI: 10.1038/s41598-022-25171-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022] Open
Abstract
We aimed to study the impact of leukoaraiosis (LA) and blood pressure (BP) on clinical outcome, mortality and symptomatic intracerebral hemorrhage (sICH) in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). We analyzed data retrospectively from 521 patients with anterior large vessel occlusion treated with MT. LA was dichotomized in 0-2 (absent-to-moderate) versus 3-4 (moderate-to-severe) according to the van Swieten scale. Various systolic (SBP) and diastolic (DBP) BP parameters during the first 24 h were collected. Multivariable logistic regressions were performed to identify predictors of a poor 90-day outcome, mortality and sICH. LA was significantly associated with poor outcome (OR 3.2; p < 0.001) and mortality (OR 3.19; p = 0.008), but not sICH (p = 0.19). Higher maximum SBP was significantly associated with poor outcome (OR per 10 mmHg increase = 1.21; p = 0.009) and lower mean DBP was a predictor of mortality (OR per 10 mmHg increase = 0.53; p < 0.001). In the univariate analysis high SBP variability was associated with poor outcome, mortality and sICH, but not in the multivariate model. There was no association between BP and sICH. Severity of LA, SBP variability, high maximum SBP and low DBP are associated with either poor outcome or mortality in AIS patients undergoing MT. However, neither LA nor BP were associated with sICH in our cohort. Thus, mechanisms of the negative impact on outcome remain unclear. Further studies on impact of BP course and its mechanisms and interventions are needed to improve outcome in patients undergoing MT.
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Prasad A, Kobsa J, Kodali S, Bartolome D, Begunova L, Quispe-Orozco D, Farooqui M, Zevallos C, Ortega-Gutiérrez S, Anadani M, Almallouhi E, Spiotta AM, Giles JA, Keyrouz SG, Kim JT, Maier IL, Liman J, Psychogios MN, Riou-Comte N, Richard S, Gory B, Quintero Wolfe S, Brown PA, Fargen KM, Mistry EA, Fakhri H, Mistry A, Wong KH, Nascimento FA, Kan P, de Havenon A, Sheth KN, Petersen NH. Temporal profiles of systolic blood pressure variability and neurologic outcomes after endovascular thrombectomy. Eur Stroke J 2022; 7:365-375. [PMID: 36478756 PMCID: PMC9720854 DOI: 10.1177/23969873221106907] [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: 01/18/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Observational studies have found an increased risk of hemorrhagic transformation and worse functional outcomes in patients with higher systolic blood pressure variability (BPV). However, the time-varying behavior of BPV after endovascular thrombectomy (EVT) and its effects on functional outcome have not been well characterized. Patients and methods We analyzed data from an international cohort of patients with large-vessel occlusion stroke who underwent EVT at 11 centers across North America, Europe, and Asia. Repeated time-stamped blood pressure data were recorded for the first 72 h after thrombectomy. Parameters of BPV were calculated in 12-h epochs using five established methodologies. Systolic BPV trajectories were generated using group-based trajectory modeling, which separates heterogeneous longitudinal data into groups with similar patterns. Results Of the 2041 patients (age 69 ± 14, 51.4% male, NIHSS 15 ± 7, mean number of BP measurements 50 ± 28) included in our analysis, 1293 (63.4%) had a poor 90-day outcome (mRS ⩾ 3) or a poor discharge outcome (mRS ⩾ 3). We identified three distinct SBP trajectories: low (25%), moderate (64%), and high (11%). Compared to patients with low BPV, those in the highest trajectory group had a significantly greater risk of a poor functional outcome after adjusting for relevant confounders (OR 2.2; 95% CI 1.2-3.9; p = 0.008). In addition, patients with poor outcomes had significantly higher systolic BPV during the epochs that define the first 24 h after EVT (p < 0.001). Discussion and conclusions Acute ischemic stroke patients demonstrate three unique systolic BPV trajectories that differ in their association with functional outcome. Further research is needed to rapidly identify individuals with high-risk BPV trajectories and to develop treatment strategies for targeting high BPV.
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Affiliation(s)
- Ayush Prasad
- Department of Neurology, Yale
University School of Medicine, New Haven, CT, USA
| | - Jessica Kobsa
- Department of Neurology, Yale
University School of Medicine, New Haven, CT, USA
| | - Sreeja Kodali
- Department of Neurology, Yale
University School of Medicine, New Haven, CT, USA
| | - David Bartolome
- Department of Neurology, Yale
University School of Medicine, New Haven, CT, USA
| | - Liza Begunova
- Department of Neurology, Yale
University School of Medicine, New Haven, CT, USA
| | - Darko Quispe-Orozco
- Department of Neurology, University of
Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mudassir Farooqui
- Department of Neurology, University of
Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Cynthia Zevallos
- Department of Neurology, University of
Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Mohammad Anadani
- Departments of Neurology, Medical
University of South Carolina, Charleston, SC, USA
| | - Eyad Almallouhi
- Departments of Neurology, Medical
University of South Carolina, Charleston, SC, USA
| | - Alejandro M Spiotta
- Departments of Neurosurgery, Medical
University of South Carolina, Charleston, SC, USA
| | - James A Giles
- Department of Neurology, Washington
University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Salah G Keyrouz
- Department of Neurology, Washington
University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam
National University Medical School, Gwangju, South Korea
| | - Ilko L Maier
- Department of Neurology, University
Medical Center Göttingen, Göttingen, Germany
| | - Jan Liman
- Department of Neurology, University
Medical Center Göttingen, Göttingen, Germany
| | - Marios-Nikos Psychogios
- Department of Diagnostic and
Interventional Neuroradiology, University Clinic Basel, Basel, Switzerland
| | | | - 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 Diagnostic and
Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
- IADI, INSERM U1254, University of
Lorraine, Nancy, France
| | | | - Patrick A Brown
- Departments of Radiology, Wake Forest
School of Medicine, Winston-Salem, NC, USA
| | - Kyle M Fargen
- Departments of Neurosurgery, Wake
Forest School of Medicine, Winston-Salem, NC, USA
| | - Eva A Mistry
- Department of Neurology and
Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Hiba Fakhri
- Department of Neurology, Vanderbilt
University Medical Center, Nashville, TN
| | - Akshitkumar Mistry
- Department of Neurosurgery,
University of Louisville, Louisville, KY, USA
| | - Ka-Ho Wong
- Department of Neurology, University
of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Peter Kan
- Department of Neurology, Baylor
College of Medicine, Houston, TX, USA
| | - Adam de Havenon
- Department of Neurology, Yale
University School of Medicine, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale
University School of Medicine, New Haven, CT, USA
| | - Nils H Petersen
- Department of Neurology, Yale
University School of Medicine, New Haven, CT, USA
- Nils H Petersen, Division of Neurocritical
Care and Emergency Neurology, Department of Neurology, Yale Medical School, 15
York Street, LCI 1003, New Haven, CT 06510, USA.
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5
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Lu Y, Shen R, Lin W, Zhou X, Hu J, Zhang Q. Association between blood pressure variability and clinical outcomes after successful recanalization in patients with large vessel occlusion stroke after mechanical thrombectomy. Front Neurol 2022; 13:967395. [PMID: 36034274 PMCID: PMC9399916 DOI: 10.3389/fneur.2022.967395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022] Open
Abstract
Objective Nearly half of patients who undergo mechanical thrombectomy (MT) do not experience a favorable outcome. The association between blood pressure fluctuation and clinical outcomes after successful MT is controversial. We evaluated the influence of blood pressure variability (BPV) on the clinical outcomes of stroke patients with large vessel occlusion (LVO) who underwent successful recanalization after MT. Methods Patients with anterior circulation LVO stroke who underwent successful emergency MT (modified Thrombolysis in Cerebral Infarction, mTICI ≥ 2b) at the Shanghai Tenth People's Hospital of Tongji University from 2017 to 2021 were enrolled. Multivariate logistic models were used to investigate the association between BPV (mean arterial pressure [MAP] assessed using the standard deviation [SD]) and clinical outcomes. The primary outcome was 90-day modified Rankin Scale scores (mRS), and the secondary outcomes were 30-day mortality and symptomatic intracranial hemorrhage (sICH). Results A total of 458 patients (56.8% men), with a mean age of 72 ± 1 years, were enrolled. Among them, 207 (45.2%) patients had unfavorable functional outcomes (mRS score 3–6) at 90 days, 61 (13.3%) patients died within 30 days, and 20 (4.4%) patients had sICH. In a fully adjusted model, BPV was associated with a higher risk of a 90-day mRS score of 3–6 (P = 0.04), 30-day mortality (P < 0.01), and sICH (P < 0.01). A significant interaction between MAP SD and rescue futile recanalization treatment was observed (P < 0.01). Conclusions Among patients with LVO stroke who underwent successful recanalization, higher BPV was associated with worse functional outcomes, especially in those who underwent rescue treatment.
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Affiliation(s)
- You Lu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Shen
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenjian Lin
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoyu Zhou
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Hu
- Department of Radiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- Jian Hu
| | - Quanbin Zhang
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Quanbin Zhang
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Hawkes MA, Anderson C, Rabinstein AA. Blood Pressure Variability After Cerebrovascular Events—A Possible New Therapeutic Target: A Narrative Review. Neurology 2022; 99:150-160. [DOI: 10.1212/wnl.0000000000200856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/29/2022] [Indexed: 11/15/2022] Open
Abstract
Blood pressure variability, the variation of blood pressure during a certain period, results from the interaction of hemodynamic, neuronal, humoral, behavioral, and environmental factors. Cerebral autoregulation is impaired in acute cerebrovascular disease. In these patients, increased blood pressure variability may provoke or exacerbate secondary brain injury. In fact, available data showed that increased Blood pressure variability is associated with worse outcomes after acute ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage. Consequently, blood pressure variability may represent a usual modifiable therapeutic target. This concept this particularly attractive because reduction of blood pressure variability can be feasible in regions with lower resources and can be applicable to patients with various forms of acute stroke. Prospective studies are needed to further clarify the relationship between blood pressure variability and secondary brain damage, and the determinants of blood pressure variability in different clinical populations. Ultimately, cerebrovascular disease-specific randomized controlled trials aimed at reducing blood pressure variability, irrespective of the absolute blood pressure values, are needed to determine if reduction of blood pressure variability can improve outcomes in patients with acute cerebrovascular disease.
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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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The First 24 h Hemodynamic Management in NICU after Revascularization Surgery in Moyamoya Disease. Behav Neurol 2021; 2021:5061173. [PMID: 34691282 PMCID: PMC8536456 DOI: 10.1155/2021/5061173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/25/2021] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate whether hemodynamic factors are risk factors for prognosis in moyamoya disease (MMD). Materials and Methods The retrospective study reviewed a single-center MMD cohort in Huashan Hospital from August 2017 to January 2020. Stroke events in 30 days and follow-up modified Rankin Scale (mRS) grade were recorded. Systematic assessments with perioperative mean arterial pressure (MAP), red blood cell (RBC) parameters, and fluid management were also conducted. Logistic regressions were applied to evaluate the predictors of worse outcomes. Data was analyzed using SPSS 24.0. Results Admission to neurological intensive care unit (NICU) totalled about 347 after revascularization surgery. The result showed that the higher the postoperative MAP level (favorable group 95.7 ± 11.4 mmHg vs. unfavorable group 103.6 ± 10.4 mmHg, p < 0.001) and the greater the MAP variability (favorable group 0.26 ± 13.2 vs. unfavorable group 7.2 ± 13.5, p = 0.006) were, the higher the patient's follow-up mRS grade was. What is more, a higher early postoperative Hb level also seemed to predict a worse long-term clinical outcome (favorable group 116.9 ± 17.1 g/L vs. unfavorable group 123.7 ± 13.0 g/L, p = 0.03), but the difference disappeared after adjusting sex and age. Logistic regression analyses showed that a higher level of postoperative MAP (β = 0.024, 95% CI (0.004, 0.044), and p = 0.02) within the first 24 h in NICU might be the short-term risk factor. For long-term outcome, a higher level (β = 1.058, 95% CI (1.022, 1.096), and p = 0.001) and a greater variability (β = 30.982, 95% CI (2.112, 454.414), and p = 0.01) of postoperative MAP might be the negative predictors of mRS grade. Conclusions The early postoperative hemodynamic management might be extremely critical for patients with MMD. Both high postoperative MAP levels and large MAP variability might affect the prognosis. What is more, we also found that a higher postoperative Hb level might be related with a worse outcome.
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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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