Blood pressure reduction and outcome after endovascular therapy with successful reperfusion: a multicenter study

BackgroundElevated systolic blood pressure (SBP) after mechanical thrombectomy (MT) correlates with worse outcome. However, the association between SBP reduction (SBPr) and outcome after successful reperfusion with MT is not well established.ObjectiveTo investigate the association between SBPr in the first 24 hours after successful reperfusion and the functional and safety outcomes of MT.MethodsA multicenter retrospective study, which included 10 comprehensive stroke centers, was carried out. Patients with acute ischemic stroke and anterior circulation large vessel occlusions who achieved successful reperfusion via MT were included. SBPr was calculated using the formula 100×([admission SBP−mean SBP]/admission SBP). Poor outcome was defined as a modified Rankin Scale (mRS) score of 3–6 at 90 days. Safety endpoints included symptomatic intracerebral hemorrhage, mortality, and requirement for hemicraniectomy during admission. A generalized mixed linear model was used to study the association between SBPr and outcomes.ResultsA total of 1361 patients were included in the final analysis. SBPr as a continuous variable was inversely associated with poor outcome (OR=0.97; 95% CI 0.95 to 0.98; p<0.001) but not with the safety outcomes. Subanalysis based on reperfusion status showed that SBPr was associated with lower odds of poor outcome only in patients with complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI 3)) but not in patients with incomplete reperfusion (mTICI 2b). When SBPr was divided into categories (<1%, 1%–10%, 11%–20%, >20%), the rate of poor outcome was highest in the first group.ConclusionSBPr in the first 24 hours after successful reperfusion was inversely associated with poor outcome. No association between SBPr and safety outcome was found.

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Blood pressure reduction and outcome after endovascular therapy: a secondary analysis of the BEST study

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016494 ◽

2020 ◽

pp. neurintsurg-2020-016494

Author(s):

Mohammad Anadani ◽

Adam de Havenon ◽

Shadi Yaghi ◽

Tapan Mehta ◽

Niraj Arora ◽

...

Keyword(s):

Blood Pressure ◽

Systolic Blood Pressure ◽

Endovascular Therapy ◽

Blood Pressure Reduction ◽

Secondary Analysis ◽

Absolute Difference ◽

Pressure Reduction ◽

Poor Outcome ◽

Outcome Group ◽

Elevated Systolic Blood Pressure

BackgroundElevated 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.ObjectiveTo determine the association between SBPr and clinical outcomes after EVT in a prospective multicenter cohort.MethodsA 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.ResultsA 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.ConclusionThe 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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Determinants and Prognostic Significance of Hematoma Sedimentation Levels in Acute Intracerebral Hemorrhage

Cerebrovascular Diseases ◽

10.1159/000442532 ◽

2015 ◽

Vol 41 (1-2) ◽

pp. 80-86 ◽

Cited By ~ 10

Author(s):

Shoichiro Sato ◽

Candice Delcourt ◽

Shihong Zhang ◽

Hisatomi Arima ◽

Emma Heeley ◽

...

Keyword(s):

Blood Pressure ◽

Intracerebral Hemorrhage ◽

Scale Score ◽

Controlled Trial ◽

Blood Pressure Reduction ◽

Prognostic Significance ◽

Logistic Regression Models ◽

Elevated Systolic Blood Pressure ◽

Acute Intracerebral Hemorrhage ◽

Post Hoc

Background: This study aimed at identifying the determinants and prognostic significance of a sedimentation level (fluid-blood level) in the hematoma among patients with acute intracerebral hemorrhage (ICH) who participated in the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). Methods: Post-hoc analysis of the INTERACT2 dataset, a randomized controlled trial of patients with acute ICH with elevated systolic blood pressure (SBP), randomly assigned to intensive (target SBP <140 mm Hg) or guideline-based (<180 mm Hg) BP management. Patients with a sedimentation level at baseline assessment on CT, and modified Rankin Scale score at 90-day, were included in these analyses. Factors associated with a sedimentation level and its significance in relation to 90-day clinical outcomes were assessed in univariable and multivariable logistic regression models. Results: Of 2,065 participants, 19 (1%) had sedimentation level on baseline CT, which was independently associated with warfarin use (p = 0.006) and lobar ICH (p = 0.025). Sedimentation level was also associated with death or major disability at 90-day in both crude (84 vs. 53%; p = 0.014) and multivariable analyses adjusted for age, gender, Chinese region, warfarin use, baseline National Institutes of Health Stroke Scale score, onset to CT time, volume and location of ICH, intraventricular extension, and randomized intensive BP lowering (OR 3.94, 95% CI 1.01-15.37; p = 0.049). Conclusions: The presence of hematoma sedimentation level on baseline CT is associated with warfarin use and lobar location of ICH, and predicts a worse outcome. Although uncommon, sedimentation level is an easily detectable prognostic factor in acute ICH.

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Abstract 3688: Factors Associated with Individual Variations in Systolic Blood Pressure Responsive to Intravenous Antihypertensive Medication. Results from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) Study

Stroke ◽

10.1161/str.43.suppl_1.a3688 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Adnan I Qureshi ◽

Yuko Y Palesch ◽

Renee Martin ◽

Jill Novitzke ◽

Salvador Cruz Flores ◽

...

Keyword(s):

Blood Pressure ◽

Systolic Blood Pressure ◽

Ct Scan ◽

Antihypertensive Medication ◽

Maximum Dose ◽

Hematoma Expansion ◽

Poor Responders ◽

Hematoma Volume ◽

Poor Outcome ◽

Elevated Systolic Blood Pressure

Introduction: There is considerable variation in blood pressure response to intravenous antihypertensive medication within patients with intracerebral hemorrhage (ICH). Objective: To study the variation in systolic blood pressure (SBP) responsiveness to IV nicardipine infusion and effect of various baseline factors on such responsiveness. We also studied the effect of SBP responsiveness on hematoma expansion, perihematomal edema, and three month outcome among subjects with ICH. Material and Methods: A post-hoc analysis of a multicenter prospective study recruiting subjects with ICH and elevated systolic blood pressure (SBP)≥170 mm Hg who presented within 6 hours of symptom onset was performed. Baseline SBP was calculated using the average of maximum and minimum SBP recorded prior to initiation of treatment. The SBP responsiveness was defined by the ratio between maximum change in SBP (difference between initial SBP and minimum SBP within the first hour) and maximum dose of nicardipine used in the first hour. This value was dichotomized at the median of 8.0, and we defined those with higher values to be responders and lower to be non-responders. We evaluated the effect of SBP reduction (relative to initial SBP) on: (1) hematoma expansion, defined as an increase in the volume of intraparenchymal hemorrhage of >33% measured on the 24-hour computed tomographic (CT) scan compared with the baseline CT scan; (2) relative edema expansion, defined as increase of >40% in edema volume to hematoma volume ratio between baseline and 24-hour CT scan; and (3) poor outcome defined by modified Rankin scale (mRS) of 4-6 at 3 months following treatment. Results: A total of 56 subjects were treated with IV nicardipine (aged 62 ±15 years; 57% men). The initial mean serum glucose was higher, although not statistically significant, among the 29 responders compared with 27 poor responders (148±72 versus 125±41). There were no clinically meaningful differences in the patient’s age, initial hematoma volume, initial Glasgow Coma Scale score, serum creatinine, or previous use of antihypertensive medication between responders and poor responders. The mean maximum dose of IV nicardipine used was 6.9 (±4.2) mg/hr and mean maximum reduction of SBP of 55.4 (±32.0) mm Hg within the first hour. The risk of poor outcome (mRS 4-6) in the responder was 10% less relative to the non-responders (relative risk [RR]=0.90, 95% confidence interval [CI]: 0.48, 1.69; n=50). The RRs were 0.81 (95% CI: 0.34, 1.93; n=54) for hematoma expansion >33%; and 0.89 (95% CI: 0.52, 1.53; n=51) for relative edema expansion >40%. Conclusions: There is considerable variation in blood pressure responsiveness to intravenous antihypertensive medication with potential prognostic implications. The variation in responsiveness does not appear to be influenced by other patient related factors that are known to influence functional outcome from ICH.

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Blood Pressure After Endovascular Thrombectomy

Stroke ◽

10.1161/strokeaha.119.026914 ◽

2020 ◽

Vol 51 (2) ◽

pp. 519-525 ◽

Cited By ~ 2

Author(s):

Marius Matusevicius ◽

Charith Cooray ◽

Matteo Bottai ◽

Michael Mazya ◽

Georgios Tsivgoulis ◽

...

Keyword(s):

Blood Pressure ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Functional Independence ◽

Optimal Level ◽

Continuous Variable ◽

Endovascular Thrombectomy ◽

Logistic Regression Models ◽

Symptomatic Intracerebral Hemorrhage ◽

Multivariable Analyses

Background and Purpose— The optimal level for blood pressure after endovascular thrombectomy in acute ischemic stroke is not well established. We sought to evaluate the association of post-endovascular thrombectomy systolic blood pressure (SBP) levels with clinical outcomes. Methods— We included endovascular thrombectomy–treated patients registered from 2014 to 2017 in the Safe Implementation of Treatments in Stroke International Thrombectomy Registry. The mean 24-hour SBP after endovascular thrombectomy treatment was analyzed both as a continuous variable and in intervals. The primary outcome was 3-month functional independence (modified Rankin Scale score of 0–2). The secondary outcomes were symptomatic intracerebral hemorrhage (SICH) and 3-month mortality. The SBP interval with the highest proportion of functional independence was chosen as reference. All analyses were performed for successful or unsuccessful recanalization (modified Treatment in Cerebral Ischemia score ≥2b or <2b, respectively). The results were adjusted for known confounders in logistic regression models. Results— In the multivariable analyses, a higher SBP value as a continuous variable was associated unfavorably with all outcomes in patients with successful recanalization (n=2920) and with more SICH in patients with unsuccessful recanalization (n=711). SBP interval ≥160 mm Hg was associated with less functional independence (adjusted odds ratio, 0.28 [95% CIs, 0.15–0.53]) and more SICH (adjusted odds ratio, 6.82 [95% CIs, 1.53–38.09]) compared with reference 100 to 119 mm Hg in patients with successful recanalization. SBP ≥160 mm Hg was associated with more SICH (adjusted odds ratio, 6.62 [95% CIs, 1.07–51.05]) compared with reference 120 to 139 mm Hg in patients with unsuccessful recanalization. Conclusions— Higher SBP values were associated with less functional independence at 3 months in patients with successful recanalization and with more SICH regardless of recanalization status.

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