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

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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Blood pressure variability and outcomes after mechanical thrombectomy based on the recanalization and collateral status

Therapeutic Advances in Neurological Disorders ◽

10.1177/1756286421997383 ◽

2021 ◽

Vol 14 ◽

pp. 175628642199738

Author(s):

Xianjun Huang ◽

Hongquan Guo ◽

Lili Yuan ◽

Qiankun Cai ◽

Min Zhang ◽

...

Keyword(s):

Blood Pressure ◽

Clinical Outcomes ◽

Functional Outcomes ◽

Mechanical Thrombectomy ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Lower Likelihood ◽

Symptomatic Intracranial Hemorrhage ◽

The Relationship ◽

Maximum Minimum

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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Impact of Blood Pressure Visit‐to‐Visit Variability on Adverse Events in Patients With Nonvalvular Atrial Fibrillation: Subanalysis of the J‐RHYTHM Registry

Journal of the American Heart Association ◽

10.1161/jaha.120.018585 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Eitaro Kodani ◽

Hiroshi Inoue ◽

Hirotsugu Atarashi ◽

Ken Okumura ◽

Takeshi Yamashita ◽

...

Keyword(s):

Atrial Fibrillation ◽

Blood Pressure ◽

Adverse Events ◽

Coefficient Of Variation ◽

Adverse Outcomes ◽

Nonvalvular Atrial Fibrillation ◽

Unique Identifier ◽

Major Hemorrhage ◽

Hazard Ratios ◽

Post Hoc

Background Blood pressure (BP) variability has reportedly been a risk factor for various clinical events. To clarify the influence of BP visit‐to‐visit variability on adverse events in patients with nonvalvular atrial fibrillation, a post hoc analysis of the J‐RHYTHM Registry was performed. Methods and Results Of 7406 outpatients with nonvalvular atrial fibrillation from 158 institutions, 7226 (age, 69.7±9.9 years; men, 70.7%), in whom BP was measured 4 times or more (14.6±5.0 times) during the 2‐year follow‐up period or until occurrence of an event, constituted the study group. SD and coefficient of variation of BP values were calculated as BP variability. Thromboembolism, major hemorrhage, and all‐cause death occurred in 110 (1.5%), 121 (1.7%), and 168 (2.3%) patients, respectively. When patients were divided into quartiles of systolic BP‐SD (<8.20, 8.20–10.49, 10.50–13.19, and ≥13.20 mm Hg), hazard ratios (HRs) for all adverse events were significantly high in the highest quartile compared with the lowest quartile (HR, 2.00, 95% CI, 1.15–3.49, P =0.015 for thromboembolism; HR, 2.60, 95% CI, 1.36–4.97, P =0.004 for major hemorrhage; and HR, 1.85, 95% CI, 1.11–3.07, P =0.018 for all‐cause death) after adjusting for components of the CHA 2 DS 2 ‐VASc score, warfarin and antiplatelet use, atrial fibrillation type, BP measurement times, and others. These findings were consistent when BP‐coefficient of variation was used instead of BP‐SD. Conclusions Systolic BP visit‐to‐visit variability was significantly associated with all adverse events in patients with nonvalvular atrial fibrillation. Further studies are needed to clarify the causality between BP variability and adverse outcomes in patients with nonvalvular atrial fibrillation. Registration URL: https://www.umin.ac.jp/ctr/ ; Unique Identifier: UMIN000001569.

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Blood Pressure Management After Endovascular Thrombectomy

Frontiers in Neurology ◽

10.3389/fneur.2021.723461 ◽

2021 ◽

Vol 12 ◽

Author(s):

Teng J. Peng ◽

Santiago Ortega-Gutiérrez ◽

Adam de Havenon ◽

Nils H. Petersen

Keyword(s):

Blood Pressure ◽

Treatment Strategies ◽

Standard Of Care ◽

Functional Independence ◽

Future Research ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Blood Pressure Targets ◽

Neuroprotective Strategy

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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Thrombectomy 24 hours after stroke: beyond DAWN

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013923 ◽

2018 ◽

Vol 10 (11) ◽

pp. 1039-1042 ◽

Cited By ~ 33

Author(s):

Shashvat M Desai ◽

Diogo C Haussen ◽

Amin Aghaebrahim ◽

Alhamza R Al-Bayati ◽

Roberta Santos ◽

...

Keyword(s):

Functional Independence ◽

Efficacy And Safety ◽

Large Vessel Occlusion ◽

Inclusion Criteria ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Symptomatic Intracranial Hemorrhage ◽

Baseline Characteristics ◽

Trial Intervention

Background and purposeThe results of the DAWN trial support the benefit of thrombectomy in patients with anterior circulation large vessel occlusion (LVO) acute stroke presenting within 6–24 hours from time last known well (TLKW). We sought to evaluate the characteristics and outcomes of patients who met DAWN criteria but underwent thrombectomy beyond 24 hours of TLKW.MethodsA retrospective review of endovascular thrombectomy databases at three comprehensive stroke centers was performed to identify all patients who received thrombectomy beyond 24 hours of TLKW and otherwise met the DAWN criteria. Baseline characteristics, efficacy, and safety outcomes were compared with patients in the DAWN trial intervention arm.ResultsTwenty-one patients met the inclusion criteria. Rates of successful reperfusion (mTICI2b–3: 81% vs 84%, P=0.72), 90-day functional independence (modified Rankin Scale score 0–2, 43% vs 48%, P=0.68), and symptomatic intracranial hemorrhage (5% vs 6%, P=0.87) were comparable across the two groups.ConclusionThrombectomy appears to be safe and feasible in patients with acute ischemic stroke due to LVO meeting all DAWN trial criteria but treated beyond 24 hours of TLKW with outcomes comparable to patients in the DAWN trial intervention arm. Further studies are warranted to validate these findings.

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Efficient Multimodal MRI Evaluation for Endovascular Thrombectomy of Anterior Circulation Large Vessel Occlusion

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2020.105271 ◽

2020 ◽

Vol 29 (12) ◽

pp. 105271

Author(s):

Kunakorn Atchaneeyasakul ◽

David S. Liebeskind ◽

Reza Jahan ◽

Sidney Starkman ◽

Latisha Sharma ◽

...

Keyword(s):

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Multimodal Mri ◽

Mri Evaluation

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Abstract MP33: Association Between Neurologic Outcomes and Temporal Profile of Systolic Blood Pressure Variability After Endovascular Thrombectomy

Stroke ◽

10.1161/str.52.suppl_1.mp33 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ayush Prasad ◽

Jessica Kobsa ◽

Sreeja Kodali ◽

Cindy Khanh Nguyen ◽

Darko Quispe Orozco ◽

...

Keyword(s):

Blood Pressure ◽

Standard Deviation ◽

Systolic Blood Pressure ◽

Functional Outcome ◽

Blood Pressure Variability ◽

Treatment Strategies ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Increased Risk ◽

Systolic Blood Pressure Variability

Introduction: Higher systolic blood pressure variability (BPV) after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and worse functional outcomes. However, the time-varying behavior of BPV after EVT and its effects on functional outcome have not been well characterized. Methods: We analyzed data from an international cohort of patients with acute 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 hours after thrombectomy. Parameters of BPV were calculated in 12-hour epochs using five established methodologies: standard deviation (SD), coefficient of variation (CV), average real variability (ARV), successive variation (SV), and residual SD (rSD). Patients’ overall mean BPV was then used to assign patients into tertiles for regression analysis: low BPV, intermediate BPV, and high BPV. Functional outcome was measured with the modified Rankin Scale (mRS) at 90 days. Results: Of the 1,791 patients (age 69 ± 14, NIHSS 15 ± 6) included in our analysis, 1,085 (60.6%) had a poor 90-day outcome (mRS >3). Patients with poor outcome had significantly higher systolic BPV (p<0.05) measured as standard deviation (SBP SD) at each epoch (Figure 1B). Compared to patients with low BPV, those in the highest tertile group had significantly greater odds of a poor functional outcome after adjusting for age, sex, hypertension, NIHSS, ASPECT, tPA, time to reperfusion, and TICI score (OR 1.5; 95% CI 1.2-2; p=0.001). Patients in the highest tertile of BPV demonstrated time-dependent variability with the highest SBP SD during the first 24 hours after thrombectomy (Figure 1A). Conclusions: Higher BPV measured by SBP SD appears to be associated with poor 90-day outcome in EVT-treated stroke patients. Early treatment strategies targeting early high BPV warrant further prospective investigation.

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Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis

Neurology ◽

10.1212/wnl.0000000000013049 ◽

2021 ◽

pp. 10.1212/WNL.0000000000013049

Author(s):

Aristeidis H Katsanos ◽

Konark Malhotra ◽

Niaz Ahmed ◽

Georgios Seitidis ◽

Eva A. Mistry ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Individual Patient Data ◽

Patient Data ◽

Neurological Deterioration ◽

Endovascular Thrombectomy ◽

Early Neurological Deterioration ◽

Symptomatic Intracranial Hemorrhage

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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Abstract WP280: A Potential Scoring System to Predict Infarct Progression During Inter Facility Transfer of Patients for Endovascular Thrombectomy Evaluation

Stroke ◽

10.1161/str.51.suppl_1.wp280 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sujan Teegala Reddy ◽

Elliott Friedman ◽

Tzu-Ching Wu ◽

Xu Zhang ◽

Jing Zhang ◽

...

Keyword(s):

Systems Of Care ◽

Youden Index ◽

Coefficient Estimates ◽

Anterior Circulation ◽

Eligibility Criteria ◽

Vessel Occlusion ◽

Hub And Spoke ◽

Endovascular Thrombectomy ◽

Stroke Systems Of Care ◽

Current Guidelines

Introduction: Current guidelines recommend CT ASPECTS≥6 as eligibility criteria for endovascular thrombectomy (EVT), a proven therapy for anterior circulation large vessel occlusion (ACLVO). Infarct progression during inter-facility transfer can render many patients ineligible for EVT. We developed a score utilizing clinical and imaging variables to predict infarct progression. Methods: Patients with ACLVO transferred from a referring hospital (RH) to our EVT capable center between August 2015 and December 2018 were reviewed. Significant predictors (p<0.10) of infarct progression, defined as CT ASPECTS of ≥6 at RH to <6 at hub, were identified using a logistic regression model. Regression coefficient estimates were used to score selected variables. The optimal cut-point was selected based on evaluated Youden index. Results: A total of 132 patients were analyzed. Score ranged from 0 to theoretical limit 18 (table 1): CTA collateral score (2/3/4=0, 0/1=3), Clot location (not ICA/M2=0, M2=2, ICA/M1=3), NIHSS (0-14=0, ≥15=5), use of antiplatelet by history (Yes=0, No=3), CT ASPECTS at RH (10=0, 6-9=2). Patients with score of ≥10.0 were more likely to have infarct progression (OR=22.15, 95% CI 4.99 - 98.35, p<0.001). Conclusions: Our score utilizing clinical and imaging variables provides information on which patients with ACLVO may undergo infarct progression during inter-facility transfer. We plan to externally validate our findings in another hub and spoke network. This score may potentially aid decisions to develop stroke systems of care to triage patients with ACLVO within hub and spoke networks.

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Thrombectomy for acute ischemic stroke in nonagenarians compared with octogenarians

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015147 ◽

2019 ◽

Vol 12 (3) ◽

pp. 266-270 ◽

Cited By ~ 7

Author(s):

Eric S Sussman ◽

Blake Martin ◽

Michael Mlynash ◽

Michael P Marks ◽

David Marcellus ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Independence ◽

Inclusion Criteria ◽

Related Factors ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Improved Outcomes ◽

Symptomatic Intracranial Hemorrhage ◽

The Difference

IntroductionMultiple randomized trials have shown that endovascular thrombectomy (EVT) leads to improved outcomes in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Elderly patients were poorly represented in these trials, and the efficacy of EVT in nonagenarian patients remains uncertain.MethodsWe performed a retrospective cohort study at a single center. Inclusion criteria were: age 80–99, LVO, core infarct <70 mL, and salvageable penumbra. Patients were stratified into octogenarian (80–89) and nonagenarian (90–99) cohorts. The primary outcome was the ordinal score on the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included dichotomized functional outcome (mRS ≤2 vs mRS ≥3), successful revascularization, symptomatic intracranial hemorrhage (ICH), and mortality.Results108 patients met the inclusion criteria, including 79 octogenarians (73%) and 29 nonagenarians (27%). Nonagenarians were more likely to be female (86% vs 58%; p<0.01); there were no other differences between groups in terms of demographics, medical comorbidities, or treatment characteristics. Successful revascularization (TICI 2b–3) was achieved in 79% in both cohorts. Median mRS at 90 days was 5 in octogenarians and 6 in nonagenarians (p=0.09). Functional independence (mRS ≤2) at 90 days was achieved in 12.5% and 19.7% of nonagenarians and octogenarians, respectively (p=0.54). Symptomatic ICH occurred in 21.4% and 6.4% (p=0.03), and 90-day mortality rate was 63% and 40.9% (p=0.07) in nonagenarians and octogenarians, respectively.ConclusionsNonagenarians may be at higher risk of symptomatic ICH than octogenarians, despite similar stroke- and treatment-related factors. While there was a trend towards higher mortality and worse functional outcomes in nonagenarians, the difference was not statistically significant in this relatively small retrospective study.

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Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time

Stroke ◽

10.1161/strokeaha.119.028626 ◽

2020 ◽

Vol 51 (5) ◽

pp. 1613-1615 ◽

Cited By ~ 3

Author(s):

Alexandra L. Czap ◽

Noopur Singh ◽

Ritvij Bowry ◽

Amanda Jagolino-Cole ◽

Stephanie A. Parker ◽

...

Keyword(s):

Computed Tomography ◽

Computed Tomography Angiography ◽

Stroke Unit ◽

Interquartile Range ◽

National Institutes Of Health ◽

Unique Identifier ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Unit Management ◽

Mobile Stroke Unit

Background and Purpose— Endovascular thrombectomy (ET) door-to-puncture time (DTPT) is a modifiable metric. One of the most important, yet time-consuming steps, is documentation of large vessel occlusion by computed tomography angiography (CTA). We hypothesized that obtaining CTA on board a Mobile Stroke Unit and direct alert of the ET team shortens DTPT by over 30 minutes. Methods— We compared DTPT between patients having CTA onboard the Mobile Stroke Unit then subsequent ET from September 2018 to November 2019 and patients in Mobile Stroke Unit from August 2014 to August 2018, when onboard CTA was not yet being used. We also correlated DTPT with change in National Institutes of Health Stroke Scale between baseline and 24 hours. Results— Median DTPT was 53.5 (95% CI, 35–67) minutes shorter with onboard CTA and direct ET team notification: 41 minutes (interquartile range, 30.0–63.5) versus 94.5 minutes (interquartile range, 69.8–117.3; P <0.001). Median on-scene time was 31.5 minutes (interquartile range, 28.8–35.5) versus 27.0 minutes (interquartile range, 23.0–31.0) ( P <0.001). Shorter DTPT correlated with greater improvement of National Institutes of Health Stroke Scale (correlation=−0.2, P =0.07). Conclusions— Prehospital Mobile Stroke Unit management including on-board CTA and ET team alert substantially shortens DTPT. Registration— URL: https://clinicaltrials.gov ; Unique identifier: NCT02190500.

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