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 ◽  
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.

Abstract MP36: Blood Pressure Reductions in the Hyperacute Phase of Large Vessel Occlusion Ischemic Stroke Are Associated With Infarct Progression and Poor Functional Outcome

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Krithika Umesh Peshwe ◽  
Cindy Khanh Nguyen ◽  
Sreeja Kodali ◽  
Jessica Kobsa ◽  
Ayush Prasad ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Linear Regression ◽  
Functional Outcome ◽  
Linear Regression Analysis ◽  
Large Vessel ◽  
Series Data ◽  
Large Vessel Occlusion ◽  
Poor Functional Outcome ◽  
Vessel Occlusion ◽  
Hemodynamic Variables

Introduction: Decreases in blood pressure (BP) during endovascular therapy (EVT) have been associated with infarct progression and worse outcome after large vessel occlusion (LVO) stroke. However, BP trajectories in the hyperacute phase prior to EVT have not been well characterized. We used high-frequency BP and hemodynamic monitoring to study the timing of BP reductions during the hyperacute period of stroke and evaluated their relation to infarct progression and functional outcome. Methods: We prospectively enrolled patients with anterior circulation LVO stroke undergoing EVT. BP and cardiac hemodynamic variables were recorded every 20 seconds from ER admission until the end of EVT using non-invasive finger plethysmography. Patients underwent initial CT perfusion imaging and a follow-up MRI at 24 hours to calculate infarct growth. The following hemodynamic parameters were defined as exposure variables: the difference between admission MAP and lowest MAP (ΔMAP), MAP drop> 20% from admission, MAP<70 mmHg, and SBP<140 mmHg. Functional outcome was measured with the modified Rankin Scale (mRS) at 90 days. Core associations between BP reductions and outcomes were studied using linear regression and logistic regression models. Results: 45 patients underwent continuous BP monitoring (age 72±17; 58% female; NIHSS 13±6). Aggregated time series data revealed a marked BP reduction around the time of imaging from which patients recovered (mean SBP 33 mmHg, duration 18 min). A sustained decrease in BP was observed after groin puncture without return to baseline BP levels. A linear regression analysis revealed a 13ml infarct growth for every 10 mmHg reduction in ΔMAP (p=0.054). Patients were divided into two groups based on median ΔMAP = 29. Those with ΔMAP ≤29 had better functional outcome at 90 days (34.78% vs. 9.09%, p = 0.038). Conclusion: Marked and frequently iatrogenic BP reductions occur around the time of initial imaging and may present a potential target for therapeutic intervention. Decrease in blood pressure before reperfusion may increase the risk of infarct progression and poor functional outcome. Changes in cardiac hemodynamic variables throughout the acute stroke period suggest a potential role for fluid resuscitation for hemodynamic optimization.

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

Stroke ◽  
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.

scholarly journals Hemodynamic Status During Endovascular Stroke Treatment: Association of Blood Pressure with Functional Outcome

2021 ◽  
Author(s):  
Min Chen ◽  
Dorothea Kronsteiner ◽  
Johannes Pfaff ◽  
Simon Schieber ◽  
Laura Jäger ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Standard Deviation ◽  
Functional Outcome ◽  
Scale Score ◽  
Endovascular Therapy ◽  
National Institutes Of Health ◽  
Modified Rankin Scale ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
The Mean

Abstract Background Optimal blood pressure (BP) management during endovascular stroke treatment in patients with large-vessel occlusion is not well established. We aimed to investigate associations of BP during different phases of endovascular therapy with reperfusion and functional outcome. Methods We performed a post hoc analysis of a single-center prospective study that evaluated a new simplified procedural sedation standard during endovascular therapy (Keep Evaluating Protocol Simplification in Managing Periinterventional Light Sedation for Endovascular Stroke Treatment). BP during endovascular therapy in patients was managed according to protocol. Data from four different phases (baseline, pre-recanalization, post recanalization, and post intervention) were obtained, and mean BP values, as well as changes in BP between different phases and reductions in systolic BP (SBP) and mean arterial pressure (MAP) from baseline to pre-recanalization, were used as exposure variables. The main outcome was a modified Rankin Scale score of 0–2 three months after admission. Secondary outcomes were successful reperfusion and change in the National Institutes of Health Stroke Scale score after 24 h. Multivariable linear and logistic regression models were used for statistical analysis. Results Functional outcomes were analyzed in 139 patients with successful reperfusion (defined as thrombolysis in cerebral infarction grade 2b–3). The mean (standard deviation) age was 76 (10.9) years, the mean (standard deviation) National Institutes of Health Stroke Scale score was 14.3 (7.5), and 70 (43.5%) patients had a left-sided vessel occlusion. Favorable functional outcome (modified Rankin Scale score 0–2) was less likely with every 10-mm Hg increase in baseline (odds ratio [OR] 0.76, P = 0.04) and pre-recanalization (OR 0.65, P = 0.011) SBP. This was also found for baseline (OR 0.76, P = 0.05) and pre-recanalization MAP (OR 0.66, P = 0.03). The maximum Youden index in a receiver operating characteristics analysis revealed an SBP of 163 mm Hg and MAP of 117 mm Hg as discriminatory thresholds during the pre-recanalization phase to predict functional outcome. Conclusions In our protocol-based setting, intraprocedural pre-recanalization BP reductions during endovascular therapy were not associated with functional outcome. However, higher intraprocedural pre-recanalization SBP and MAP were associated with worse functional outcome. Prospective randomized controlled studies are needed to determine whether BP is a feasible treatment target for the modification of outcomes.

Comparison of 24-Hour Ambulatory Blood Pressure Data in Hypertensive Patients Switched from Nifedipine-GITS to Nifedipine-CC

1999 ◽  
Vol 19 (1) ◽  
pp. 94-100 ◽  
Author(s):  
Richard L. Wurdeman ◽  
Aryan N. Mooss ◽  
Syed M. Mohiuddin ◽  
B. Daniel Lucas ◽  
Kay L. Ryschon ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ambulatory Blood Pressure ◽  
Pressure Data ◽  
Hypertensive Patients ◽  
Blood Pressure Data

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

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
David S Liebeskind ◽  
Graham W Woolf ◽  
Nerses Sanossian ◽  
Jason D Hinman ◽  
Radoslav Raychev ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Arterial Occlusion ◽  
Patient Specific ◽  
Pressure Data ◽  
Blood Pressure Data ◽  
Pressure Changes ◽  
Continuous Blood Pressure

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.

Abstract WMP17: Computerized Tomography Perfusion to Characterize Lack of Clinical Improvement After Recanalization in Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Alvaro Garcia-Tornel ◽  
Marta Olive-Gadea ◽  
Marc Ribo ◽  
David Rodriguez-Luna ◽  
Jorge Pagola ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Infarct Volume ◽  
Significant Proportion ◽  
Hemorrhagic Transformation ◽  
Vessel Occlusion ◽  
Clinical Recovery ◽  
Good Functional Outcome ◽  
Significant Difference

A significant proportion of patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) present poor functional outcome despite recanalization. We aim to investigate computed tomography perfusion (CTP) patterns after EVT and their association with outcome Methods: Prospective study of anterior large vessel occlusion AIS patients who achieved complete recanalization (defined as modified Thrombolysis in Cerebral Ischemia (TICI) 2b - 3) after EVT. CTP was performed within 30 minutes post-EVT recanalization (POST-CTP): hypoperfusion was defined as volume of time to maximal arrival of contrast (Tmax) delay ≥6 seconds in the affected territory. Hyperperfusion was defined as visual increase in cerebral blood flow (CBF) and volume (CBV) with advanced Tmax compared with the unaffected hemisphere. Dramatic clinical recovery (DCR) was defined as a decrease of ≥8 points in NIHSS score at 24h or NIHSS≤2 and good functional outcome by mRS ≤2 at 3 months. Results: One-hundred and forty-one patients were included. 49 (34.7%) patients did not have any perfusion abnormality on POST-CTP, 60 (42.5%) showed hypoperfusion (median volume Tmax≥6s 17.5cc, IQR 6-45cc) and 32 (22.8%) hyperperfusion. DCR appeared in 56% of patients and good functional outcome in 55.3%. Post-EVT hypoperfusion was related with worse final TICI, and associated worse early clinical evolution, larger final infarct volume (p<0.01 for all) and was an independent predictor of functional outcome (OR 0.98, CI 0.97-0.99, p=0.01). Furthermore, POST-CTP identified patients with delayed improvement: in patients without DCR (n=62, 44%), there was a significant difference in post-EVT hypoperfusion volume according to functional outcome (hypoperfusion volume of 2cc in good outcome vs 11cc in poor outcome, OR 0.97 CI 0.93-0.99, p=0.04), adjusted by confounding factors. Hyperperfusion was not associated with worse outcome (p=0.45) nor symptomatic hemorrhagic transformation (p=0.55). Conclusion: Hypoperfusion volume after EVT is an accurate predictor of functional outcome. In patients without dramatic clinical recovery, hypoperfusion predicts good functional outcome and defines a “stunned-brain” pattern. POST-CTP may help to select EVT patients for additional therapies.

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

Stroke ◽  
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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