Abstract TMP89: Collaterals and Reperfusion Mediate Blood Pressure Changes in Acute Ischemic Stroke

Background: The pathophysiology and optimal management of blood pressure changes in acute ischemic stroke remain unknown. Blood pressure guidelines do not consider patient-specific or serial data on dynamic blood pressure readings. We investigated continuous blood pressure data during endovascular therapy for acute stroke to discern changes associated with collaterals, recanalization and reperfusion. Methods: Continuous monitoring blood pressure data was collected in consecutive cases of endovascular therapy for acute ischemic stroke due to ICA or proximal MCA occlusion. Angiography details were independently analyzed to document site of arterial occlusion, baseline collateral grade, time of device deployments, time of recanalization, time of final reperfusion, final AOL recanalization and final TICI reperfusion. Statistical analyses correlated instantaneous and serial blood pressure changes with these angiographic parameters. Results: 80 patients (median age 73 years; 33 women) were studied. Arterial lesions included 37 ICA and 41 proximal M1 MCA occlusions. Collateral grade prior to intervention included 2 ASITN grade 4, 26 grade 3, 23 grade 2, 6 grade 1 and 0 grade 0. oTICI2C reperfusion scores after thrombectomy included 2 TICI 3 (100%), 22 TICI 2C (90-99%), 25 TICI o2B (67-89%), 9 TICI m2B (50-66%), 19 TICI 2A (<50%) and 3 TICI 0/1. More robust collateral grade was associated with greater reperfusion scores (r=0.32, p=0.028). The change in blood pressure (ΔBP) from earliest BP to time of recanalization was mean 59% of ΔBP during the entire procedure. Better collaterals were associated with lower BP prior to recanalization (r=-0.377, p=0.012). Lower BP prior to recanalization was linked with greater TICI reperfusion (r=-0.242, p=0.050). Higher TICI reperfusion scores were also associated with a greater drop or ΔBP at the time of recanalization (r=0.269, p=0.031). AOL recanalization was not related to ΔBP. Conclusions: Collaterals and reperfusion, but not recanalization, mediate blood pressure changes in acute ischemic stroke. Prospective, precision medicine stroke studies should leverage patient-specific, real-time data on continuous blood pressure with imaging correlates to define BP goals of future in-hospital management.

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Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review

Frontiers in Neurology ◽

10.3389/fneur.2020.573382 ◽

2020 ◽

Vol 11 ◽

Author(s):

Benjamin Maïer ◽

François Delvoye ◽

Julien Labreuche ◽

Simon Escalard ◽

Jean-Philippe Desilles ◽

...

Keyword(s):

Systematic Review ◽

Blood Pressure ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy

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Blood pressure changes in acute ischemic stroke and outcome with respect to stroke etiology

Neurology ◽

10.1212/wnl.0b013e31826d5ed6 ◽

2012 ◽

Vol 79 (14) ◽

pp. 1440-1448 ◽

Cited By ~ 12

Author(s):

G. Ntaios ◽

D. Lambrou ◽

P. Michel

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Etiology ◽

Pressure Changes

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Timeline of blood pressure changes after intra-arterial therapy for acute ischemic stroke based on recanalization status

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012369 ◽

2016 ◽

Vol 9 (5) ◽

pp. 455-458 ◽

Cited By ~ 14

Author(s):

Seby John ◽

Walaa Hazaa ◽

Ken Uchino ◽

Muhammad S Hussain

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Artery Occlusion ◽

Vessel Occlusion ◽

Short Period ◽

Successful Group ◽

History Of ◽

Pressure Changes ◽

Cerebral Artery Occlusion

BackgroundThere is sparse literature on the natural history of blood pressure (BP) after intra-arterial therapy (IAT) for acute ischemic stroke (AIS).MethodsA retrospective analysis was performed of patients with AIS who underwent IAT without endotracheal intubation for internal carotid artery terminus (ICA-T) or M1 middle cerebral artery occlusion from January 2008 to February 2012. Systolic BP (SBP) values at the beginning (First) and end (End) of IAT and for 36 h after the procedure were collected. Successful recanalization was defined as Thrombolysis In Cerebral Infarction (TICI) 2b–3.ResultsSixty-two patients (14 (22.5%) ICA-T, 46 (74.2%) M1, 2 (3.2%) ICA-T+M1) met the study criteria and 37 (59.7%) achieved successful recanalization. The First and End SBP values were similar in the successful (Group R) and unsuccessful (Group NR) recanalization groups. Taking the whole cohort, End SBP was significantly lower than First SBP, but this decline was significant only in Group R. Subsequently, absolute SBP values in Group R were not significantly different from Group NR. However, when comparing the hourly decline of SBP with First SBP, Group R demonstrated a greater fall than Group NR and the decline was significantly different from hours 8 to 12 post-procedure. The SBP in Group NR then decreased further, and its difference from baseline was similar to Group R from hour 14 onwards. Mean SBP and SBP variability over 36 h were similar between the two groups.ConclusionsSBP falls significantly in patients with AIS with large vessel occlusion who recanalize with IAT. While SBP in non-recanalized patients also drops from baseline, it occurs to a lesser degree and stays higher only for a short period of time before falling to similar levels as in recanalized patients.

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E.09 Predictors of optimal endovascular therapy results among patients with acute ischemic stroke

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2016.93 ◽

2016 ◽

Vol 43 (S2) ◽

pp. S18-S18

Author(s):

D Catana ◽

J Badhiwala ◽

A Koziarz ◽

K Reddy ◽

SA Almenawer

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Mechanical Thrombectomy ◽

Combined Therapy ◽

Arterial Occlusion ◽

Functional Independence ◽

Sensitivity Analyses ◽

Care Group ◽

Functional Benefit

Background: Several studies have demonstrated the safety and efficacy of endovascular therapy for patients with acute ischemic stroke. However, patient, imaging and treatment factors associated with the optimal functional outcome require better definition. Methods: We pooled data from 8 randomized controlled trials (SYNTHESIS, MR RESCUE, IMS III, MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, and REVASCAT). We conducted subgroup and sensitivity analyses to evaluate predictors of optimal functional results (modified Rankin scale, mRS) at 90 days. Results: Meta-analysis of 8 trials including 2,423 patients yielded that endovascular therapy resulted in 44.6% functional independence (mRS 0-2) versus 31.8% in the usual care group (OR 1.71, 95% CI 1.18-2.49, P=0.005). This treatment effect was significantly greater among patients with confirmed angiographic imaging of proximal arterial occlusion (OR 2.24, 95% CI 1.72-2.90, P<0.001), in patients who received the combined therapy of intravenous tPA and endovascular intervention (OR 2.07, 95% CI 1.46-2.92, P<0.001), and when using stent retriever for mechanical thrombectomy (OR 2.39, 95% CI 1.88-3.04, P<0.001). Conclusions: The relative functional benefit associated with endovascular therapy among patients with acute ischemic stroke was increased when combined with intravenous tPA, with confirmed proximal arterial occlusion on angiographic imaging, and with use of stent retrievers for mechanical thrombectomy.

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Occult blood flow patterns distal to an occluded artery in acute ischemic stroke

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x211044941 ◽

2021 ◽

pp. 0271678X2110449

Author(s):

Nerea Arrarte Terreros ◽

Bettine G van Willigen ◽

Wera S Niekolaas ◽

Manon L Tolhuisen ◽

Josje Brouwer ◽

...

Keyword(s):

Blood Flow ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Arterial Occlusion ◽

Flow Patterns ◽

Study Patient ◽

Patient Specific ◽

Collateral Flow ◽

Large Variability ◽

Blood Flow Patterns

Residual blood flow distal to an arterial occlusion in patients with acute ischemic stroke (AIS) is associated with favorable patient outcome. Both collateral flow and thrombus permeability may contribute to such residual flow. We propose a method for discriminating between these two mechanisms, based on determining the direction of flow in multiple branches distal to the occluding thrombus using dynamic Computed Tomography Angiography (dynamic CTA). We analyzed dynamic CTA data of 30 AIS patients and present patient-specific cases that identify typical blood flow patterns and velocities. We distinguished patterns with anterograde (N = 10), retrograde (N = 9), and both flow directions (N = 11), with a large variability in velocities for each flow pattern. The observed flow patterns reflect the interplay between permeability and collaterals. The presented method characterizes distal flow and provides a tool to study patient-specific distal tissue perfusion.

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Abstract 177: The Association of Blood Pressure and Pretreatment Arterial Collaterals in Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.177 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Beisi Jiang ◽

Leonid Churilov ◽

Lasheta Kanesan ◽

Richard Dowling ◽

Peter Mitchell ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Time Delay ◽

Acute Ischemic Stroke ◽

Negative Binomial ◽

Ct Perfusion ◽

Arterial Occlusion ◽

Negative Binomial Regression Model ◽

Arterial Blood ◽

Filling Time

Introduction: Leptomeningeal collaterals maintain arterial perfusion in acute arterial occlusion but may fluctuate subject to arterial blood pressure (ABP). We aim to investigate the relationship between ABP and collaterals as assessed by CT perfusion in acute ischemic stroke. Methods: We retrospectively analyzed acute anterior circulation ischemic stroke patients with CT perfusion from 2009 to 2014. Collateral status using relative filling time delay (rFTD) determined by time delay of collateral-derived contrast opacification within the Sylvian fissure, from 0 seconds to unlimited count. The data were analyzed by zero-inflated negative binomial regression model including an appropriate interaction examining in the model in terms of occlusion location and onset-to-CT time (OCT). Results: Two hundred and seventy patients were included. We found that increment of 10mm Hg in BP, the odds that a patient would have rFTD equal to 0 seconds increased by 27.9% in SBP (P=0.001), by 73.9% in diastolic blood pressure (DBP) (P<0.001) and by 68.5% in mean blood pressure (MBP) (P<0.001). For patients with rFTD not necessarily equal to 0 seconds, every 10mm Hg increase in BP, there was a 7% decrease in expected count of seconds for rFTD in SBP (P=0.002), 10% decrease for rFTD in DBP and 11% decrease for rFTD in MBP. The arterial occlusion location and OCT showed no significant interaction in the BP-rFTD relationship (P>0.05). Conclusions: In acute ischemic stroke, higher ABP is associated with improved leptomeningeal collaterals as identified by decreased rFTD.

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Abstract W P47: Recanalization After IV TPA Alone Among Acute Ischemic Stroke Patients Treated With Combined IV-Endovascular Recanalization: Impact of Arterial Occlusion Site

Stroke ◽

10.1161/str.45.suppl_1.wp47 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Seo Hyun Kim ◽

David Liebeskind ◽

Reza Jahan ◽

Sidney Starkman ◽

Latisha Ali ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Endovascular Therapy ◽

Multivariate Logistic Regression Analysis ◽

Arterial Occlusion ◽

High Rate ◽

Large Artery ◽

Diagnostic Catheter ◽

Iv Tpa

Background: Combined IV TPA and catheter-based reperfusion is an emerging treatment strategy for acute ischemic stroke. Both patient care and clinical trial design would be enhanced by delineation of which patients rapidly respond to IV TPA alone, before endovascular therapy can be initiated. Methods: In a prospectively maintained registry of patients treated under a general policy of combined IV TPA and endovascular therapy, we analyzed subjects with MRA/CTA-confirmed anterior circulation occlusions prior to IV TPA start. Results: Among 118 patients meeting study entry criteria, age was mean 71.5 (SD 14.5), 53.0% were female, and baseline NIHSS was 14.4 (SD 7.1). Confirmed sites of occlusion prior to IV TPA were internal cerebral artery (ICA) in 22.9%, M1 segment of middle cerebral artery (MCA) in 50.0%, and M2-3 in 27.1%. Among patients undergoing catheter cerebral angiography, median time from start of IV TPA to diagnostic catheter angiogram was 75 mins (IQR 50-113). A total of 48 (40.7%) patients achieved partial or complete recanalization (AOL 2-3) of the initial target artery with IV TPA alone (partial in 22 (18.6%) and complete in 26 (22.2%)); an additional 44 (37.3%) achieved partial or complete recanalization after endovascular therapy. Recanalization rates after IV TPA alone varied by target occlusion site: ICA - 22.2%, M1 - 40.7%, and M2-3 - 56.2%. In multivariate logistic regression analysis, independent predictors of recanalization with IV TPA alone were: M2-3 clot location, OR 3.04 (95% CI 1.20-7.73, p=0.019) and TOAST etiology large-artery atherosclerosis, OR 0.14 (CI 0.04-0.50, p = 0.003). Good outcome (mRS ≤ 3) rates at 3 months were 76.6% among recanalizers with IV TPA alone and 47.5% among recanalizers after both IV TPA and catheter therapy. Conclusions: When combined IV-endovascular treatment is pursued, recanalization with IV TPA alone occurs in 4 out of 10 patients before catheter therapy is started, is more common with more distal clot location, and is associated with a high rate of excellent clinical outcomes.

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Early blood pressure management for endovascular therapy in acute ischemic stroke: A review of the literature

Interventional Neuroradiology ◽

10.1177/1591019920931651 ◽

2020 ◽

Vol 26 (6) ◽

pp. 785-792

Author(s):

Bin Han ◽

Xuan Sun ◽

Xu Tong ◽

Raynald ◽

Baixue Jia ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Systolic Blood Pressure ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Mechanical Thrombectomy ◽

Clinical History ◽

Normal Range ◽

Vessel Occlusion ◽

Blood Pressure Targets

The perioperative optimal blood pressure targets during mechanical thrombectomy for acute ischemic stroke are uncertain, and randomized controlled trials addressing this issue are lacking. There is still no consensus on the optimal target for perioperative blood pressure in acute ischemic stroke patients with large vessel occlusion. In addition, there are many confounding factors that can influence the outcome including the patient’s clinical history and stroke characteristics. We review the factors that have an impact on perioperative blood pressure change and discuss the influence of perioperative blood pressure on functional outcome after mechanical thrombectomy. In conclusion, we suggest that blood pressure should be carefully and flexibly managed perioperatively in patient-received mechanical thrombectomy. Blood pressure changes during mechanical thrombectomy were independently correlated with poor prognosis, and blood pressure should be maintained in a normal range perioperatively. Postoperative blood pressure control is associated with recanalization status in which successful recanalization requires normal range blood pressure (systolic blood pressure 120–140 mmHg), while non-recanalization requires higher blood pressure (systolic blood pressure 160–180 mmHg). The preoperative blood pressure targets for mechanical thrombectomy should be tailored based on the patient’s clinical history (systolic blood pressure ≤185 mmHg). Blood pressure should be carefully and flexibly managed intraoperatively (systolic blood pressure 140–180 mmHg) in patient-received endovascular therapy.

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