Abstract NS 4: Non-Invasive Oscillometric Blood Pressure Monitoring in tPA Treated Patients: Is Mean Arterial Pressure Associated with Patient Outcomes?

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Anne W Alexandrov ◽  
Asad A Chaudhary ◽  
April Sisson ◽  
Kara Sands ◽  
Pawan Rawal ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Intracerebral Hemorrhage ◽  
Acute Stroke ◽  
National Standard ◽  
Stroke Patients ◽  
Non Invasive ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stroke Center

Background: Blood pressure (BP) parameters for management of tPA treated patients are well known among experienced stroke clinicians, and violation of systolic and diastolic BP limits have previously been shown to be associated with symptomatic intracerebral hemorrhage (sICH) in tPA treated patients. Non-invasive oscillometric BP monitoring measures a “true” mean arterial pressure (MAP), and then algorithmically defines what systolic and diastolic pressure "might" be. Because this form of BP monitoring has become the national standard, we examined the occurrence of MAP BP elevations to determine their association with sICH and treatment outcome in acute ischemic stroke patients that received systemic tPA. Methods: Two-years of consecutive systemic tPA cases were retrieved from our Stroke Center database and arterial blood pressures for the first 24 hours from time of bolus were entered from auto-recordings in our electronic medical records. Protocol violations in MAP were defined as greater than 120 mm Hg at any point in the first 24 hours from time of bolus. Off-label treatment with intravenous tPA beyond 4.5 hours from symptom onset was identified a priori as a potential counfounder to stroke outcome. Symptomatic intracerebral hemorrhage was defined as an increase in the NIHSS of ≥ 4 points. Spearman’s correlation was used to assess the relationship between MAP and post-tPA NIHSS score. Results: 191 tPA cases were identified for inclusion in the analysis with 150 (79%) receiving their tPA at our Comprehensive Stroke Center and another 41 (21%) administered as a telephone-consult supported drip and ship. Patients were 65.5±16 years of age with median admission NIHSS scores of 12 (IQR=7-17). All patients had normal CT scans or minor changes consistent with acute stroke without hypo-attenuation. A total of 77 (40%) patients experienced a MAP violation overall. There were 11 isolated systolic BP violations, 4 isolated diastolic BP violations, and 21 isolated MAP violations that were otherwise not detectable by a violation in systolic or diastolic parameters, averaging 123.3±2 mm Hg. A total of 2 (1%) sICHs occurred in the sample, and of these 1 was associated with on-label peri-treatment BP protocol violations affecting systolic, diastolic and MAP parameters. An increased reduction in post-tPA NIHSS points was significantly associated with higher MAPs (r=.92; p=.008). Conclusions: Evidence-based guidelines are silent on MAP limits, and MAP is rarely monitored clinically in tPA treated patients despite dependence on the MAP for assignment of systolic and diastolic pressures in oscillometric BP monitoring. Our findings suggest that an improved understanding of the contribution of MAP-dependent oscillometric methods to BP monitoring in acute stroke patients is warranted.

scholarly journals PREDIKTOR SYMPTOMATIC INTRACEREBRAL HEMORRHAGE PASCATROMBOLISIS INTRAVENA PADA STROKE ISKEMIK AKUT

2018 ◽  
Vol 35 (3) ◽  
Author(s):  
Al Rasyid ◽  
Salim Harris ◽  
Mohammad Kurniawan ◽  
Rakhmad Hidayat ◽  
Taufik Mesiano
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Intravenous Thrombolysis ◽  
Definitive Treatment ◽  
Stroke Patients ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stroke Thrombolysis ◽  
Withholding Therapy ◽  
Diabetes Melitus

PREDICTORS OF SYMPTOMATIC INTRACEREBRAL HEMORRHAGE FOLLOWING INTRAVENOUS THROMBOLYSIS IN ACUTE ISCHEMIC STROKEABSTRACTDespite its effectiveness, the percentage of ischemic stroke patients who received definitive treatment, thrombolysis, never went above 10%, due to one of the reason is the occurrence of severe, post-therapeutic complications, such as symptomatic intracerebral hemorrhage (sICH). Several factors contribute to sICH occurrence are age, severity of stroke, early changes of ischemic sign, hyperglycemia, blood pressure, antiplatelet use and its interval. Patients with highest risk of sICH has been shown to have the greatest benefits from thrombolysis among other subgroup patients, therefore withholding therapy is not a choice. Compliance to the stroke’s guidelines could reduce the risk of complications as well as boost effectiveness of treatment.Keywords: Safety predictors, acute ischemic stroke, thrombolysis, sICH ABSTRAK Walau terbukti efektif, persentase pasien yang dapat dilakukan tindakan definitif stroke iskemik akut berupa trombolisis  tidak  pernah  mencapai  angka  10%,  salah  satunya  disebabkan  pertimbangan  terhadap  komplikasi  berat, seperti symptomatic intracerebral hemorrhage (sICH). Beberapa faktor yang berpengaruh terhadap kejadian sICH antara lain usia, derajat stroke, perubahan tanda iskemik dini, hiperglikemia dan diabetes melitus, tekanan darah, penggunaan antiplatelet, serta waktu pemberian. Pasien dengan risiko sICH tertinggi memiliki keuntungan terbesar dari trombolisis sehingga menunda tindakan bukanlah suatu opsi. Kepatuhan terhadap panduan tindakan dapat mengurangi angka kejadian komplikasi berat.Kata kunci: Prediktor keamanan, stroke iskemik akut, trombolisis, sICH

Abstract WP126: Association of 24-Hour Blood Pressure Parameters Post-Intravenous Alteplase With Symptomatic Intracerebral Hemorrhage

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Taha Nisar ◽  
Toluwalase Tofade ◽  
Ava Liberman ◽  
Priyank Khandelwal
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Treatment Time ◽  
Tertiary Care ◽  
Significant Risk ◽  
Binary Logistic Regression Analysis ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Intravenous Alteplase ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: Higher blood pressure (BP) at presentation is associated with a higher risk of symptomatic intracerebral hemorrhage (sICH) post-intravenous alteplase (IV-rtPA). We investigated the association of different BP parameters post-IV-rtPA with the development of sICH at a tertiary care center. Methods: We performed a retrospective chart review of adult patients with an acute ischemic stroke treated with IV-rtPA at a comprehensive stroke center from July 2014 to March 2018. We excluded patients who underwent mechanical thrombectomy. At the comprehensive stroke center, the BP values are documented according to standard post-IV-rtPA care guidelines. We recorded the BP values over a period of 24-hours post-IV-rtPA. A binary logistic regression analysis was performed, controlling for age, sex, pre-treatment NIHSS, atrial fibrillation, onset to treatment time, with the BP parameters as the predictors. The primary outcome was the development of sICH. SICH was defined as an intracerebral hemorrhage (ICH) that causes worsening of NIHSS score by ≥4 points post-IV-rtPA. Results: 84 patients met our inclusion criteria. 45 (53.57%) patients were male. The mean age was 63.50±15 years. 5 (5.95%) patients developed sICH. In our cohort, the BP parameters of higher maximum systolic blood pressure (SBP) (195.8±9 vs.172.22±17; OR, 1.14; 95% CI, 1.03-1.26; P 0.016), higher maximum diastolic blood pressure (DBP) (120.2±18 vs.104.76±15; OR, 1.08; 95% CI, 1.01-1.17; P 0.04), wider SBP range (79.4±20 vs.58.75±18; OR, 1.06; 95% CI, 1.01-1.12; P 0.033), wider DBP range (74.2±27 vs.47.27±15; OR, 1.11; 95% CI, 1.03-1.2; P 0.008), and coefficient variation (CV) DBP (17.7±6 vs.12.65±4; OR, 1.19; 95% CI, 1.01-1.42; P 0.048) were significantly associated with a risk of sICH post IV-rtPA. Conclusions: Our study demonstrates significant risk of sICH with higher maximum SBP and DBP, wider SBP and DBP ranges, and CV DBP post-IV-rtPA.

Abstract 513: Impaired Hemodynamic Response to Head up Tilt in Adolescents Presenting with Chronic Nausea and Orthostatic Intolerance

Hypertension ◽  
2014 ◽  
Vol 64 (suppl_1) ◽  
Author(s):  
Hossam A Shaltout ◽  
Ashley L Wagoner ◽  
John E Fortunato ◽  
Debra I Diz
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Orthostatic Intolerance ◽  
Frequency Method ◽  
Non Invasive ◽  
Head Up Tilt ◽  
Blood Pressures ◽  
Chronic Nausea

We previously reported that ~70% of adolescents presenting to a Pediatric GI clinic for chronic nausea exhibit orthostatic intolerance (OI) in response to head upright tilt testing (HUT). The objective of this study was to determine whether supine mean arterial pressure or hemodynamic responses to HUT differ in these patients. Forty-eight patients (mean age of 15 [10-18] years, 36 females) completed a 45 minutes 0 to 70° HUT. Continuous blood pressure and heart rate recordings were acquired using non-invasive finger cuff. Thirteen subjects had normal tilt (Normal) while thirty five demonstrated OI. There were no differences between the two groups in supine blood pressures (BP), baroreflex sensitivity measured by frequency method in HF range (BRS), heart rate variability (HRV) measured as the root of mean square of successive differences (rMSSD), blood pressure variability (BPV) measured as standard deviation of mean arterial pressure (SDMAP) or the sympathovagal balance measure LF RRI /HF RRI . HUT caused a greater increase in heart rate in OI group (from 71 ± 6 beats/min to 104 ± 4 in OI vs from 75 ± 3 to 95 ±3 in normal, p=0.01) which was accompanied with lesser increase in BP (mainly due to lack of increase in diastolic) in the OI group. There was a trend for greater reduction in BRS in OI subjects (from 28.5 ± 13 ms/mm Hg to 6.3 ± 0.8 in OI vs from 21.1 ± 3.6 to 12.0 ± 2.9 in normal, p=0.09). HUT impaired HRV in both groups compared to supine values but the reduction was greater in OI group (-66.7 ± 4 % vs -52.0 ±5.6 in normal, p=<0.001). SDMAP increased by HUT compared to supine but to a greater extent in OI (40.6 ± 4 % vs 13.4 ± 8 in normal, p=0.02). LF RRI /HF RRI increased to a greater magnitude in OI group with HUT (from 1.8 ± 0.8 to 6.8 ± 0.8 in OI vs from 1.14 ± 0.18 to 4.1 ±0.7 in normal, p=0.02). These data reveal that the adolescents with orthostatic intolerance have attenuated parasympathetic responses and exaggerated activation of the sympathetic system to the heart and blood vessels. Despite these responses, subjects fail to maintain BP. Similar to previous studies in other subjects with OI, the excessive tachycardia often followed by syncope in most of these adolescents may reflect a loss of vascular responses to the activation of sympathetic and neurohumoral stimuli. Support: AHA12CRP9420029

Central Triage of Acute Stroke Patients Across a Distributive Stroke Network Is Safe and Reduces Transfer Denials

Stroke ◽  
2021 ◽  
Author(s):  
Derek Holder ◽  
Kevin Leeseberg ◽  
James A. Giles ◽  
Jin-Moo Lee ◽  
Sheyda Namazie ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Similar Rate ◽  
Study Data ◽  
Clinical Severity ◽  
Community Hospitals ◽  
Stroke Patients ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Primary Stroke Center ◽  
Stroke Center

Background and Purpose: Mechanical thrombectomy has dramatically increased patient volumes transferred to comprehensive stroke centers (CSCs), resulting in transfer denials for patients who need higher level of care only available at a CSC. We hypothesized that a distributive stroke network (DSN), triaging low severity acute stroke patients to a primary stroke center (PSC) upon initial telestroke consultation, would safely reduce transfer denials, thereby providing additional volume to treat severe strokes at a CSC. Methods: In 2017, a DSN was implemented, in which mild stroke patients were centrally triaged, via telestroke consultation, to a PSC based upon a simple clinical severity algorithm, while higher acuity/severity strokes were triaged to the CSC. In an observational cohort study, data on acute ischemic stroke patients presenting to regional community hospitals were collected pre- versus post-DSN implementation. Safety outcomes and rate of CSC transfer denials were compared pre-DSN versus post-DSN. Results: The pre-DSN cohort (n=150), triaged to the CSC, had a similar rate of symptomatic intracerebral hemorrhage and discharge location compared with the post-DSN cohort (n=150), triaged to the PSC. Time to stroke unit admission was faster post-DSN (2 hours 40 minutes) versus pre-DSN (3 hours 29 minutes; P <0.001). Transfer denials were reduced post-DSN (3.8%) versus pre-DSN (1.8%; P =0.02), despite an increase in telestroke consultation volume over the same period (median, 3 calls pre-DSN versus 5 calls post-DSN; P =0.001). No patients who were triaged to the PSC required subsequent transfer to the CSC. Conclusions: A DSN, triaging mild ischemic stroke patients from community hospitals to a PSC, safely reduced transfer denials to the CSC, allowing greater capacity at the CSC to treat higher acuity stroke patients.

scholarly journals A Novel MRA-Based Framework for Segmenting the Cerebrovascular System and Correlating Cerebral Vascular Changes to Mean Arterial Pressure

2021 ◽  
Vol 11 (9) ◽  
pp. 4022
Author(s):  
Fatma Taher ◽  
Heba Kandil ◽  
Yitzhak Gebru ◽  
Ali Mahmoud ◽  
Ahmed Shalaby ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Surrounding Tissue ◽  
Final Visit ◽  
P Value ◽  
Cerebral Vasculature ◽  
Tree Model ◽  
Non Invasive ◽  
Cerebrovascular System

Blood pressure (BP) changes with age are widespread, and systemic high blood pressure (HBP) is a serious factor in developing strokes and cognitive impairment. A non-invasive methodology to detect changes in human brain’s vasculature using Magnetic Resonance Angiography (MRA) data and correlation of cerebrovascular changes to mean arterial pressure (MAP) is presented. MRA data and systemic blood pressure measurements were gathered from patients (n = 15, M = 8, F = 7, Age = 49.2 ± 7.3 years) over 700 days (an initial visit and then a follow-up period of 2 years with a final visit.). A novel segmentation algorithm was developed to delineate brain blood vessels from surrounding tissue. Vascular probability distribution function (PDF) was calculated from segmentation data to correlate the temporal changes in cerebral vasculature to MAP calculated from systemic BP measurements. A 3D reconstruction of the cerebral vasculature was performed using a growing tree model. Segmentation results recorded 99.9% specificity and 99.7% sensitivity in identifying and delineating the brain’s vascular tree. The PDFs had a statistically significant correlation to MAP changes below the circle of Willis (p-value = 0.0007). This non-invasive methodology could be used to detect alterations in the cerebrovascular system by analyzing MRA images, which would assist clinicians in optimizing medical treatment plans of HBP.

scholarly journals Measurement of mean arterial pressure: comparison of the Vasotrac monitor with the finger differential oscillometric device

2010 ◽  
pp. 691-696 ◽  
Author(s):  
K Jagomägi ◽  
R Raamat ◽  
J Talts ◽  
U Ragun ◽  
P Tähepõld
Keyword(s):  
Blood Pressure ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Radial Artery ◽  
Blood Pressure Monitoring ◽  
Signal Conditioning ◽  
Non Invasive ◽  
Arterial Blood ◽  
Oscillometric Device ◽  
Good Agreement

The Vasotrac monitor provides non-invasive near-continuous blood pressure monitoring and is designed to be an alternative to direct intra-arterial blood pressure (BP) measurement. As compared to radial artery invasive BP and upper arm noninvasive BP, Vasotrac readings have been found to have a good agreement with them. However, discrepancies have been reported when rapid changes in BP exist. In the present study we compared BP measured by the Vasotrac monitor on the radial artery with that recorded on the finger arteries by the differential oscillometric device allowing measurement on the beat-to-beat basis. Comparisons were performed on the mean arterial pressure (MAP) level. Special attention was paid to the signal conditioning before comparison of pressures of different temporal resolution. Altogether 383 paired MAP measurements were made in 14 healthy subjects. Based on all 383 paired measurements, the MAP values measured at the radial artery at rest were 4.8±6.0 mm Hg higher than those measured on fingers. The observed difference between the Vasotrac and differential oscillometric device can be explained by different measurement sites. This result is consistent with previous investigations, and the Vasotrac monitor can be considered to adequately track relatively rapid MAP changes on the radial artery. Attention should be paid to a proper signal conditioning before comparison of results obtained by different devices.

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