Abstract 95: Exceeding Personalized Blood Pressure Targets After Endovascular Stroke Therapy is Associated With Hemorrhagic Transformation and Worse Functional Outcome

Background/Objective: Blood pressure parameters for patients undergoing mechanical thrombectomy (MT) are not clearly defined. Prior studies have shown that higher maximum and mean systolic blood pressure (SBP) is associated with adverse outcomes. Our study sought to investigate the relationship of blood pressure on clinical outcomes after successful revascularization and determine optimal thresholds for BP parameters that correlated with a poor functional outcome. Methods: This was a retrospective observational study of 88 consecutive patients who received successful MT at one comprehensive stroke center. Systolic, diastolic, and mean arterial pressure values were recorded for each patient over a 48-hour period, as well as patient age and National Institutes of Health Stroke Scale (NIHSS). Outcome measures included modified Rankin Score (mRS), intracranial hemorrhage (ICH), and mortality at time of discharge and 90 days. Both univariable and multivariable logistic regression analysis was performed to identify associations between the BP covariates and functional outcomes. Results: A higher SBP standard deviation (SD) of >14mmHg (OR=1.150) and wider SBP range >64mmHg (OR=1.037) from the mean in the first 48 hours after successful MT were associated with poor MRS at 90 days. A SBP SD>14 was also associated with mortality at 90 days. A higher age (OR=1.052) and NIHSS (OR=1.096) were also associated with a poor MRS at 90 days. A higher DBP mean (OR=1.045) was associated with a higher rate of hemorrhagic transformation (HT). Conclusions: A higher SBP variability within the first 48 hours after successful MT is associated with a higher likelihood of poor 90-day functional outcome and mortality, and a higher mean DBP is associated with a higher rate of HT.

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Abstract WP3: Decreases in Blood Pressure During Endovascular Stroke Therapy are Associated With Larger Infarct Volumes and Poor Functional Outcome

Stroke ◽

10.1161/str.50.suppl_1.wp3 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Cited By ~ 1

Author(s):

Nils H Petersen ◽

Anson Wang ◽

Binbin Zhen-Li ◽

Sumita Strander ◽

Sreeja Kodali ◽

...

Keyword(s):

Blood Pressure ◽

Functional Outcome ◽

Stroke Therapy ◽

Poor Functional Outcome ◽

Endovascular Stroke Therapy

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Blood Pressure After Endovascular Stroke Therapy-II

Case Medical Research ◽

10.31525/ct1-nct04116112 ◽

2019 ◽

Author(s):

Keyword(s):

Blood Pressure ◽

Stroke Therapy ◽

Endovascular Stroke Therapy

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Deviation from Dynamic and Personalized Optimal Blood Pressure Targets is Associated With Worse Functional Outcomes After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1093/neuros/nyz310_186 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Andrew Silverman ◽

Sreeja Kodali ◽

Sumita Strander ◽

Emily Gilmore ◽

Alexandra Kimmel ◽

...

Keyword(s):

Blood Pressure ◽

Subarachnoid Hemorrhage ◽

Functional Outcome ◽

Functional Outcomes ◽

Near Infrared ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Time Correlation ◽

Blood Pressure Targets ◽

Percent Time

Abstract INTRODUCTION Effective blood pressure (BP) management after aneurysmal subarachnoid hemorrhage (aSAH) is critical for maintaining optimal cerebral perfusion and protecting the brain from further injury. How to best manage BP during the early stages of aSAH remains uncertain. In this study, we calculated individualized BP thresholds at which cerebral autoregulation was best preserved. We analyzed how deviating from these limits correlates with functional outcome. METHODS We prospectively enrolled 31 patients with aSAH. Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy (NIRS)-derived tissue oxygenation – a surrogate for cerebral blood flow – as well as intracranial pressure (ICP) in response to changes in mean arterial pressure (MAP) using time-correlation analysis. The resulting autoregulatory indices were used to trend BP ranges at which autoregulation was most preserved. The percent time that MAP exceeded limits of autoregulation (LA) was calculated for each patient. Functional outcome was assessed using the modified Rankin Scale (mRS) at discharge and 90 d. Associations with outcome were analyzed using ordinal multivariate logistic regression. RESULTS Personalized LA were computed in all patients (age 57.5, 23F, mean WFNS 2, monitoring time 67.8 h). Optimal BP and LA were calculated on average for 89.5% of the total monitoring period. ICP- and NIRS-derived optimal pressures and LA strongly correlated with one another (P < .0001). Percent time that MAP deviated from LA significantly associated with worse functional outcome at discharge (NIRS P = .001, ICP P = .004) and 90 d (NIRS P = .002, ICP P = .003), adjusting separately for age, WFNS, vasospasm, or delayed cerebral ischemia. CONCLUSION Both invasive (ICP) and non-invasive (NIRS) determination of personalized BP thresholds for aSAH patients is feasible, and these 2 approaches revealed significant collinearity. Exceeding individualized autoregulatory thresholds may increase the risk of poor functional outcomes.

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Abstract 120: Systolic Blood Pressure Trajectories 72 Hours After Mechanical Thrombectomy Are Associated With Poor Functional Outcome: A Multicenter Analysis of Individual Patient Blood Pressure Data

Stroke ◽

10.1161/str.51.suppl_1.120 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sreeja Kodali ◽

Can Meng ◽

Sumita Strander ◽

Cindy Khanh Nguyen ◽

Andrew Silverman ◽

...

Keyword(s):

Blood Pressure ◽

Functional Outcome ◽

Latent Variable ◽

Pressure Control ◽

Hemorrhagic Transformation ◽

Pressure Data ◽

Poor Functional Outcome ◽

Vessel Occlusion ◽

Blood Pressure Data ◽

Multicenter Analysis

Introduction: Blood pressure (BP) is an important modifiable parameter after endovascular thrombectomy (EVT). Observational studies have found associations between elevated BP after EVT with hemorrhagic transformation and poor functional outcome. However, blood pressure course after EVT has not been well characterized and optimal hemodynamic management in the immediate post-stroke period remains unresolved. We utilized blood pressure data up to 72 hours after EVT to identify distinct systolic BP (SBP) trajectories and studied their associations with functional outcome. Methods: We retrospectively studied a multicenter cohort of 1060 patients with large-vessel occlusion stroke who underwent EVT. BP was recorded non-invasively recorded at least hourly for the first 72 hours. Functional outcome was assessed using the modified Rankin scale (mRS). Favorable functional outcome was defined as mRS &lt. Latent variable mixture modeling was applied to identify patient subgroups that have comparable SBP trajectories. All analyses were adjusted for age, admission NIHSS, and recanalization status. Results: One thousand sixty patients (mean age 70±15, mean NIHSS 16) were included in the analysis. Five distinct SBP trajectories were identified: (1) low (17%), (2) moderate (38%), (3) moderate-to-high (21%), (4) high-to-moderate (17%), and (5) high (7%) (Figure 1A). SBP trajectory group was an independent predictor of functional outcome at discharge (p=0.001) and 90 days (p=0.010, Figure 1B). Patients with high and high-to-moderate SBP trajectories had a significantly higher odds of an unfavorable outcome at 90 days (adjusted OR 2.3, 95%CI 1.2 - 4.3, p=0.01 and adjusted OR 4, 95% CI 1.5-10.7, p=0.06, respectively) Conclusions: During the first 72 hours after EVT, acute ischemic stroke patients show distinct SBP trajectories, which differ in relation to functional outcome. The findings may help recognize potential candidates for future blood pressure control trials.

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Abstract 94: Blood Pressure After Endovascular Stroke Therapy (BEST): Final Results of a Prospective Multicenter Cohort Validation Study

Stroke ◽

10.1161/str.50.suppl_1.94 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Eva A Mistry ◽

Heidi Sucharew ◽

Akshitkumar M Mistry ◽

Tapan Mehta ◽

Niraj Arora ◽

...

Keyword(s):

Blood Pressure ◽

Validation Study ◽

Stroke Therapy ◽

Multicenter Cohort ◽

Endovascular Stroke Therapy

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Abstract TMP88: Blood Pressure Variability Within 24 Hours After Recanalization Worsens Functional Outcome Among Patients Who Underwent Endovascular Treatment

Stroke ◽

10.1161/str.51.suppl_1.tmp88 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Daniel Campos ◽

Manuel Requena ◽

Mariana Carvalho ◽

Marlene Saraiva ◽

Alvaro Garcia-Tornel ◽

...

Keyword(s):

Blood Pressure ◽

Endovascular Treatment ◽

Functional Outcome ◽

Systemic Blood Pressure ◽

Hemorrhagic Transformation ◽

Poor Functional Outcome ◽

Ischemic Tissue ◽

Increased Risk ◽

Potential Risks

Introduction: Systemic blood pressure (BP) should be strictly monitored and adjusted during the initial stages of stroke. Due to the impairment of cerebral autoregulation, cerebral blood flow is directly affected by systemic BP and some degree of permissive hypertension might be beneficial prior to reperfusion treatments to ensure an adequate perfusion in the ischemic tissue. However, after generalization of endovascular treatment (EVT) the rate of successful recanalization has skyrocketed and it is not well established if, once achieved, BP control should be stricter given its potential risks. We aim to explore the relation between BP and outcome among patients who underwent EVT. Methods: This is a retrospective study of a prospectively acquired unicentric database that includes patients who underwent EVT with successful recanalization measured by a mTICI ≥2b. Hourly measuring of systolic and diastolic BP was conducted during the first 24 hours post-procedure. BP variation was measured using standard deviation (SD) and range. We explored the effects of BP on functional outcome at 3 months and safety variables. Results: The study included 351 subjects with a mean age of 72.7+/-13.1 and 51.6% were men. The 3-months mRS was ≤2 in 50.4% of patients, 66 subjects (19.2%) presented hemorrhagic transformation and 67 (19.1%) were dead in the 3-months follow-up period. Both systolic BP SD (15.6+/-9.9 vs. 12.9+/-4.3; p<0.01) and range (55.6+/-18.4 vs. 48.7+/-16.4; p<0.01) were higher among patients with bad functional outcome (mRS>2). Subjects with hemorrhagic transformation presented higher range of DBP (35.7+/-12.4 vs. 32.0+/-11.9; p=0.03) and SBP (56.8+/-17.0 vs. 51.4+/-18.1; p=0.03) and higher diastolic DBP SD (9.3+/-4.1 vs. 8.2+/-2.7; p<0.01). In a logistic regression analysis DBP SD predicted ICH (OR 1.11, CI 1.02-1.22, p=0.01) and SBP range emerged as a predictor of poor functional outcome (OR 0.97, CI 0.96-0.99, p<0.01). No differences were detected in regard to admission BP, maximal and minimal BP or mean arterial pressure. Conclusions: Major fluctuations in systolic and diastolic BP predict increased risk of hemorrhagic complications and poor functional outcome. Minimizing BP fluctuations may improve outcome of EVT patients after recanalization.

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