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 ◽  
...  

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.

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Sreeja Kodali ◽  
Can Meng ◽  
Sumita Strander ◽  
Cindy Khanh Nguyen ◽  
Andrew Silverman ◽  
...  

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.


Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Ayaz Khawaja ◽  
Karen Albright ◽  
Angela Hays Shapshak ◽  
Harn Shiue ◽  
April Sisson ◽  
...  

Background: Early ischemic changes (EIC) on head CT are associated with increased hemorrhagic transformation (HT) following treatment with TPA. We examined the associations between EIC, HT, and outcomes in patients treated and not treated with IV TPA. Methods: We conducted a retrospective review of consecutive acute ischemic stroke (AIS) patients presenting to our CSC from April 2014 to March 2015. Demographic and clinical data, including initial head CT findings (parenchymal hypodensity, loss of gray-white differentiation, sulcal effacement, hyperdense vessel) were collected. HT on repeat neuroimaging, poor functional outcome, as measured by a modified Rankin Scale (mRS) of 3-6, and in-hospital mortality were assessed. Results: A total of 679 patients were included (50.4% men). One hundred and eight patients (15.9%) received IV TPA. EIC were observed in 38.5% of untreated patients and 17.6% in IV TPA treated patients (p<0.0001). For patients treated with IV TPA, EIC was seen more frequently in patients with pre-stroke anticoagulant use (26.3% vs. 6.7%, p=0.010) and less frequently in patients with pre-stroke statin use (15.8% vs. 43.3%, p=0.025). A higher proportion of HT was observed in patients with EIC (12.8% vs. 6.8%, p=0.016 untreated, 36.8% vs. 14.6%, p=0.024 IV TPA) and with hyperdense artery sign (8.2% vs. 3.7%, p=0.022 untreated, 36.8% vs. 15.7%, p=0.035 IV TPA). For untreated patients, EIC was observed in a larger proportion of patients with an NIHSS>14 (14.8% vs. 9.6%, p=0.016), and discharge mRS 3-6 (53.6% vs. 44.5%, p=0.040). For patients treated with IV TPA, in-hospital mortality was more common in patients with EIC (31.6% vs. 10.0%, p=0.013). Conclusions: In untreated patients, EIC may serve as a harbinger for HT on repeat imaging and poor functional outcome at discharge, whereas in patients treated with IV TPA, it is associated with HT and in-hospital mortality. Patients with EIC may be at increased risk of HT and poor outcomes even without thrombolytics.


2021 ◽  
Vol 10 (7) ◽  
pp. 1514
Author(s):  
Hilde Espnes ◽  
Jocasta Ball ◽  
Maja-Lisa Løchen ◽  
Tom Wilsgaard ◽  
Inger Njølstad ◽  
...  

The aim of this study was to explore sex-specific associations between systolic blood pressure (SBP), hypertension, and the risk of incident atrial fibrillation (AF) subtypes, including paroxysmal, persistent, and permanent AF, in a general population. A total of 13,137 women and 11,667 men who participated in the fourth survey of the Tromsø Study (1994–1995) were followed up for incident AF until the end of 2016. Cox proportional hazards regression analysis was conducted using fractional polynomials for SBP to provide sex- and AF-subtype-specific hazard ratios (HRs) for SBP. An SBP of 120 mmHg was used as the reference. Models were adjusted for other cardiovascular risk factors. Over a mean follow-up of 17.6 ± 6.6 years, incident AF occurred in 914 (7.0%) women (501 with paroxysmal/persistent AF and 413 with permanent AF) and 1104 (9.5%) men (606 with paroxysmal/persistent AF and 498 with permanent AF). In women, an SBP of 180 mmHg was associated with an HR of 2.10 (95% confidence interval [CI] 1.60–2.76) for paroxysmal/persistent AF and an HR of 1.80 (95% CI 1.33–2.44) for permanent AF. In men, an SBP of 180 mmHg was associated with an HR of 1.90 (95% CI 1.46–2.46) for paroxysmal/persistent AF, while there was no association with the risk of permanent AF. In conclusion, increasing SBP was associated with an increased risk of both paroxysmal/persistent AF and permanent AF in women, but only paroxysmal/persistent AF in men. Our findings highlight the importance of sex-specific risk stratification and optimizing blood pressure management for the prevention of AF subtypes in clinical practice.


2021 ◽  
Vol 23 (6) ◽  
Author(s):  
A. Maud ◽  
G. J. Rodriguez ◽  
A. Vellipuram ◽  
F. Sheriff ◽  
M. Ghatali ◽  
...  

Abstract Purpose of Review In this review article we will discuss the acute hypertensive response in the context of acute ischemic stroke and present the latest evidence-based concepts of the significance and management of the hemodynamic response in acute ischemic stroke. Recent Findings Acute hypertensive response is considered a common hemodynamic physiologic response in the early setting of an acute ischemic stroke. The significance of the acute hypertensive response is not entirely well understood. However, in certain types of acute ischemic strokes, the systemic elevation of the blood pressure helps to maintain the collateral blood flow in the penumbral ischemic tissue. The magnitude of the elevation of the systemic blood pressure that contributes to the maintenance of the collateral flow is not well established. The overcorrection of this physiologic hemodynamic response before an effective vessel recanalization takes place can carry a negative impact in the final clinical outcome. The significance of the persistence of the acute hypertensive response after an effective vessel recanalization is poorly understood, and it may negatively affect the final outcome due to reperfusion injury. Summary Acute hypertensive response is considered a common hemodynamic reaction of the cardiovascular system in the context of an acute ischemic stroke. The reaction is particularly common in acute brain embolic occlusion of large intracranial vessels. Its early management before, during, and immediately after arterial reperfusion has a repercussion in the final fate of the ischemic tissue and the clinical outcome.


Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Katherine O Brag ◽  
Erica Jones ◽  
Dominique Monlezun ◽  
Alex George ◽  
Michael Halstead ◽  
...  

Introduction: Hematoma expansion (HE) is an established predictor of mortality and poor functional outcome after intracerebral hemorrhage (ICH). The computed tomography angiography (CTA) “spot” sign predicts HE and deterioration. The “dot” sign on delayed post-contrast CT (PCCT) has undetermined clinical significance but is thought to represent a slower rate of bleeding than the “spot” sign. We aimed to compare the sensitivity of a “dot” sign with the “spot” sign and establish the clinical significance of the “dot” sign. Methods: Patients with ICH presenting to our center July 2008-May 2013 were identified from our stroke registry. Only patients with baseline CT, CTA and PCCT and follow-up CT 6-36 hours later were included. Patients with clot evacuation between baseline and follow-up CT were excluded. HE was defined as 1) any ≥ 1cc increase and 2) significant ≥ 12.5cc increase or >33% increase in volume. Differences in cohort characteristics were assessed using appropriate statistical tests and sensitivity was calculated from 2x2 tables. Unadjusted logistic regression models were used to investigate the relation of “spot” and “dot” signs with HE and poor functional outcome (discharge mRS 4-6). Results: Of the 210 ICH patients included in the analyses (median age 61, 44.7% female, 66.2% black), 39 (18.5%) patients had a PCCT “dot” sign and 19 (9%) had a CTA “spot” sign. Significant HE occurred in 15% with “dot” sign and 8% with “spot” sign. The PCCT “dot” sign had a sensitivity of 0.52 in predicting significant HE and a sensitivity of 0.69 in predicting discharge mRS 4-6 (compared with 0.24 and 0.30 for “spot” sign, respectively). Patients with a “dot” sign, but without a “spot” sign, had significantly increased odds of any HE (OR 5.7, 95% CI 1.9-17.8, p=0.003), mRS 4-6 (OR 8.1, 95% CI 1.03-64.6, p=0.048), and death (OR 8.1, 95% CI 1.4-48.4, p=0.02), but not significant HE (OR 2.2, 95% CI 0.7-6.7, p=0.15). Conclusions: The PCCT “dot” sign was more sensitive in predicting hematoma expansion than the CTA “spot” sign and predicted hematoma expansion and poor functional outcome even in the absence of the “spot sign.” The utility of PCCT imaging in acute evaluation of ICH patients requires validation, but our study supports clinical relevance of the “dot” sign.


PLoS ONE ◽  
2021 ◽  
Vol 16 (6) ◽  
pp. e0249093
Author(s):  
Sabine L. Collette ◽  
Maarten Uyttenboogaart ◽  
Noor Samuels ◽  
Irene C. van der Schaaf ◽  
H. Bart van der Worp ◽  
...  

Objective The effect of anesthetic management (general anesthesia [GA], conscious sedation, or local anesthesia) on functional outcome and the role of blood pressure management during endovascular treatment (EVT) for acute ischemic stroke is under debate. We aimed to determine whether hypotension during EVT under GA is associated with functional outcome at 90 days. Methods We retrospectively collected data from patients with a proximal intracranial occlusion of the anterior circulation treated with EVT under GA. The primary outcome was the distribution on the modified Rankin Scale at 90 days. Hypotension was defined using two thresholds: a mean arterial pressure (MAP) of 70 mm Hg and a MAP 30% below baseline MAP. To quantify the extent and duration of hypotension, the area under the threshold (AUT) was calculated using both thresholds. Results Of the 366 patients included, procedural hypotension was observed in approximately half of them. The occurrence of hypotension was associated with poor functional outcome (MAP <70 mm Hg: adjusted common odds ratio [acOR], 0.57; 95% confidence interval [CI], 0.35–0.94; MAP decrease ≥30%: acOR, 0.76; 95% CI, 0.48–1.21). In addition, an association was found between the number of hypotensive periods and poor functional outcome (MAP <70 mm Hg: acOR, 0.85 per period increase; 95% CI, 0.73–0.99; MAP decrease ≥30%: acOR, 0.90 per period; 95% CI, 0.78–1.04). No association existed between AUT and functional outcome (MAP <70 mm Hg: acOR, 1.000 per 10 mm Hg*min increase; 95% CI, 0.998–1.001; MAP decrease ≥30%: acOR, 1.000 per 10 mm Hg*min; 95% CI, 0.999–1.000). Conclusions Occurrence of procedural hypotension and an increase in number of procedural hypotensive periods were associated with poor functional outcome, whereas the extent and duration of hypotension were not. Randomized clinical trials are needed to confirm our hypothesis that hypotension during EVT under GA has detrimental effects.


2021 ◽  
Vol 12 ◽  
Author(s):  
Youyu Li ◽  
Daqing Chen ◽  
Laifang Sun ◽  
Zhibo Chen ◽  
Weiwei Quan

Objective: Monocyte to high-density lipoprotein ratio is considered as a new inflammatory marker and has been used to predict the severity of coronary heart disease and the incidence of adverse cardiovascular events (ACEs). However, there is a lack of data relative to large artery atherosclerosis (LAA) ischemic stroke. We investigated whether the monocyte to high-density lipoprotein (HDL) ratio (MHR) is related to the 3-month functional prognosis of LAA ischemic stroke.Materials and Methods: A retrospective analysis was conducted on 316 LAA ischemic stroke patients. The 3-month functional outcome was divided into good and poor according to the modified Rankin Scale (mRS) score. Multivariate logistic regression analysis was performed to evaluate the correlation between MHR and prognosis of ischemic stroke.Results: The MHR level of poor functional outcome group was higher than that of the good functional outcome group [0.44 (0.3, 0.55) vs. 0.38 (0.27, 0.5), P = 0.025]. Logistic stepwise multiple regression revealed that MHR [odds ratio (OR) 9.464, 95%CI 2.257–39.678, P = 0.002] was an independent risk factor for the 3-month poor outcome of LAA ischemic stroke. Compared to the lower MHR tertile, the upper MHR tertile had a 3.03-fold increase (95% CI 1.475–6.225, P = 0.003) in the odds of poor functional outcome after adjustment for potential confounders. Moreover, a multivariable-adjusted restricted cubic spline (RCS) showed a positive close to a linear pattern of this association.Conclusion: Elevated MHR was independently associated with an increased risk of poor 3-month functional outcome of patients with LAA ischemic stroke.


Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Pedro Cardona ◽  
Helena Quesada ◽  
Blanca Lara ◽  
Nuria Cayuela ◽  
Xavier Ustrell ◽  
...  

Introduction: Multiple randomized trials have demonstrated that endovascular treatment (EVT) in selected stroke patients is associated with good clinical outcome (90 days mRankin 0-2: 44-60%). However the percentage of good functional outcome could be improved if we consider patients without cortical clinical impairment with presentation of classical lacunar syndrome despite non-lacunar radiological infarct. Methods: Consecutive patients with ischemic stroke who received endovascular reperfusion were retrospectively analyzed between May 2010 and April 2015. On admission NCCT (non-contrast CT) and CTASI (CT Angiography Source Image) were performed in stroke patients according to our hospital guidelines. We independently applied the ASPECT score in all baselines NCCT, CTASI and follow-up NCCT 24H, and magnetic resonance (MR) during hospitalization. Five pure clinical lacunar syndromes (CLS) were recorded within 24h exam after EVT in our stroke unit and 90 days follow-up Results: We review 428 thrombectomies of patients with acute ischemic stroke. Ninety-five percent of occlusions were located in middle cerebral artery or terminal internal carotid, (49% women, mean age 65+/-13 years; NIHSS at admission: 17; baseline mRS 0-1:96%). Successful recanalization (TICI 2b-3) was achieved in 81%. At 3 months good functional outcome (mRS 0-2) was seen in 51% and death occurred in 13%. CLS were indentified in 42% patients within 24h after EVT. This clinical syndromes were associated to ASPECT score in 24 NCCT and CTASI in patients with recanalization 2b-3 (p:0.003), but only 4% had a defined radiological lacunar stroke on MR. CLS turned out to be one of independence predictors of good outcomes (Rankin 0-2 at 90d) after adjustment for ages, sex and baseline NIHSS scores (OR 1.85; CI:1.4-3.1; p:0.001). Also CLS were still present in 34% of patients with Rankin>2 at 90d (Rankin 3:26%; Rankin 4:7%) Conclusions: These results suggest that a neurological exam 24h after EVT with identification of pure lacunar syndrome can predict favorable functional outcome at 90days. This group of patients presents radiological findings with an unusual location and size with regard to CLS. We suggest to consider patients with CLS as good outcome after EVT regardless 90d mRankin>2.


Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ayush Prasad ◽  
Jessica Kobsa ◽  
Sreeja Kodali ◽  
Cindy Khanh Nguyen ◽  
Darko Quispe Orozco ◽  
...  

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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