Thrombocytopenia and Clinical Outcomes in Intracerebral Hemorrhage

Background and Purpose: The impact of platelets on hematoma enlargement (HE) of intracerebral hemorrhage (ICH) is not yet sufficiently elucidated. Especially the role of reduced platelet counts on HE and clinical outcomes is still poorly understood. This study investigated the influence of thrombocytopenia on HE, functional outcome, and mortality in patients with ICH with or without prior antiplatelet therapy (APT). Methods: Individual participant data of multicenter cohort studies (multicenter RETRACE program [German-Wide Multicenter Analysis of Oral Anticoagulation-Associated Intracerebral Hemorrhage] and single-center UKER-ICH registry [Universitätsklinikum Erlangen Cohort of Patients With Spontaneous ICH]) were grouped into APT and non-APT ICH patients according to the platelet count, that is, with or without thrombocytopenia (cells <150×10 9 /L). Of all patients, 51.5% (1124 of 2183) were on vitamin K antagonist. Imbalances in baseline characteristics including proportions of vitamin K antagonist patients were addressed using propensity score matching. Outcome analyses included HE (>33%), as well as mortality and functional outcome, after 3 months using the modified Rankin Scale, dichotomized into favorable (modified Rankin Scale score, 0–3) and unfavorable (modified Rankin Scale score, 4–6). Results: Of overall 2252 ICH patients, 11.4% (52 of 458) under APT and 14.0% (242 of 1725) without APT presented with thrombocytopenia on admission. The proportion of patients with HE was not significantly different between patients with or without thrombocytopenia among APT and non-APT ICH patients after propensity score matching (HE: APT patients: 9 of 40 [22.5%] thrombocytopenia versus 27 of 115 [23.5%] nonthrombocytopenia, P =0.89; non-APT patients: 54 of 174 [31.0%] thrombocytopenia versus 106 of 356 [29.8%] nonthrombocytopenia, P =0.77). In both (APT and non-APT) propensity score matching cohorts, there were no significant differences regarding functional outcome. Mortality after 3 months did not differ among non-APT patients, whereas the mortality rate was significantly higher for APT patients with thrombocytopenia versus APT patients with normal platelet count (APT: 29 of 46 [63.0%] thrombocytopenia versus 58 of 140 [41.4%] nonthrombocytopenia, P =0.01; non-APT: 95 of 227 [41.9%] thrombocytopenia versus 178 of 455 [39.1%] nonthrombocytopenia, P =0.49). Conclusions: Our study implies that thrombocytopenia does not affect rates of HE and functional outcome among ICH patients, neither in patients with nor without APT. In light of increased mortality, the significance of platelet transfusions for ICH patients with thrombocytopenia and previous APT should be explored in future studies.

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Outcome of intracerebral hemorrhage associated with different oral anticoagulants

Neurology ◽

10.1212/wnl.0000000000003886 ◽

2017 ◽

Vol 88 (18) ◽

pp. 1693-1700 ◽

Cited By ~ 77

Author(s):

Duncan Wilson ◽

David J. Seiffge ◽

Christopher Traenka ◽

Ghazala Basir ◽

Jan C. Purrucker ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Functional Outcome ◽

Scale Score ◽

Vitamin K ◽

Pooled Analysis ◽

Vitamin K Antagonist ◽

Cox Proportional Hazards Model ◽

Hematoma Expansion ◽

All Cause Mortality ◽

International Collaborative

Objective:In an international collaborative multicenter pooled analysis, we compared mortality, functional outcome, intracerebral hemorrhage (ICH) volume, and hematoma expansion (HE) between non–vitamin K antagonist oral anticoagulation–related ICH (NOAC-ICH) and vitamin K antagonist–associated ICH (VKA-ICH).Methods:We compared all-cause mortality within 90 days for NOAC-ICH and VKA-ICH using a Cox proportional hazards model adjusted for age; sex; baseline Glasgow Coma Scale score, ICH location, and log volume; intraventricular hemorrhage volume; and intracranial surgery. We addressed heterogeneity using a shared frailty term. Good functional outcome was defined as discharge modified Rankin Scale score ≤2 and investigated in multivariable logistic regression. ICH volume was measured by ABC/2 or a semiautomated planimetric method. HE was defined as an ICH volume increase >33% or >6 mL from baseline within 72 hours.Results:We included 500 patients (97 NOAC-ICH and 403 VKA-ICH). Median baseline ICH volume was 14.4 mL (interquartile range [IQR] 3.6–38.4) for NOAC-ICH vs 10.6 mL (IQR 4.0–27.9) for VKA-ICH (p = 0.78). We did not find any difference between NOAC-ICH and VKA-ICH for all-cause mortality within 90 days (33% for NOAC-ICH vs 31% for VKA-ICH [p = 0.64]; adjusted Cox hazard ratio (for NOAC-ICH vs VKA-ICH) 0.93 [95% confidence interval (CI) 0.52–1.64] [p = 0.79]), the rate of HE (NOAC-ICH n = 29/48 [40%] vs VKA-ICH n = 93/140 [34%] [p = 0.45]), or functional outcome at hospital discharge (NOAC-ICH vs VKA-ICH odds ratio 0.47; 95% CI 0.18–1.19 [p = 0.11]).Conclusions:In our international collaborative multicenter pooled analysis, baseline ICH volume, hematoma expansion, 90-day mortality, and functional outcome were similar following NOAC-ICH and VKA-ICH.

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POST-NOAC: Portuguese observational study of intracranial hemorrhage on non-vitamin K antagonist oral anticoagulants

International Journal of Stroke ◽

10.1177/1747493016681021 ◽

2016 ◽

Vol 12 (6) ◽

pp. 623-627 ◽

Cited By ~ 11

Author(s):

Cláudia Marques-Matos ◽

José Nuno Alves ◽

João Pedro Marto ◽

Joana Afonso Ribeiro ◽

Ana Monteiro ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Functional Outcome ◽

Intracranial Hemorrhage ◽

Vitamin K ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Vitamin K Antagonist ◽

Significant Shift ◽

Modified Rankin Scale

Background There is a lower reported incidence of intracranial hemorrhage with non-vitamin K antagonist oral anticoagulants compared with vitamin K antagonist. However, the functional outcome and mortality of intracranial hemorrhage patients were not assessed. Aims To compare the outcome of vitamin K antagonists- and non-vitamin K antagonist oral anticoagulants-related intracranial hemorrhage. Methods We included consecutive patients with acute non-traumatic intracranial hemorrhage on oral anticoagulation therapy admitted between January 2013 and June 2015 at four university hospitals. Clinical and demographic data were obtained from individual medical records. Intracranial hemorrhage was classified as intracerebral, extra-axial, or multifocal using brain computed tomography. Three-month functional outcome was assessed using the modified Rankin Scale. Results Among 246 patients included, 24 (9.8%) were anticoagulated with a non-vitamin K antagonist oral anticoagulants and 222 (90.2%) with a vitamin K antagonists. Non-vitamin K antagonist oral anticoagulants patients were older (81.5 vs. 76 years, p = 0.048) and had intracerebral hemorrhage more often (83.3% vs. 63.1%, p = 0.048). We detected a non-significant trend for larger intracerebral hemorrhage volumes in vitamin K antagonists patients ( p = 0.368). Survival analysis adjusted for age, CHA2DS2VASc, HAS-BLED, and anticoagulation reversal revealed that non-vitamin K antagonist oral anticoagulants did not influence three-month mortality (hazard ratio (HR) = 0.83, 95% confidence interval (CI) = 0.39–1.80, p = 0.638). Multivariable ordinal regression for three-month functional outcome did not show a significant shift of modified Rankin Scale scores in non-vitamin K antagonist oral anticoagulants patients (odds ratio (OR) 1.26, 95%CI 0.55–2.87, p = 0.585). Conclusions We detected no significant differences in the three-month outcome between non-vitamin K antagonist oral anticoagulants- and vitamin K antagonists-associated intracranial hemorrhage, despite unavailability of non-vitamin K antagonist oral anticoagulants-specific reversal agents.

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Impact of Preexisting Cognitive Impairment and Race/Ethnicity on Functional Outcomes Following Intracerebral Hemorrhage

Stroke ◽

10.1161/strokeaha.120.030084 ◽

2021 ◽

Vol 52 (2) ◽

pp. 603-610

Author(s):

Russell P. Sawyer ◽

Eunji Yim ◽

Elisheva Coleman ◽

Stacie L. Demel ◽

Padmini Sekar ◽

...

Keyword(s):

Risk Factors ◽

Cognitive Impairment ◽

Propensity Score ◽

Intracerebral Hemorrhage ◽

Propensity Score Matching ◽

Scale Score ◽

Functional Outcomes ◽

Cognitively Impaired ◽

Modified Rankin Scale ◽

Race Ethnicity

Background and Purpose: In intracerebral hemorrhage (ICH), preexisting cognitive impairment has been identified as a risk factor for increased mortality and morbidity. However, previous studies examined predominantly White populations; therefore, the prevalence and effect of preICH cognitive impairment has not been studied in a multiethnic cohort. This limits the generalizability of previous findings. We sought to investigate the role of preexisting cognitive impairment in a multiethnic population on short-term mortality and functional outcomes after ICH. Methods: Patients with ICH were prospectively enrolled as cases for the GERFHS III (Genetic and Environmental Risk Factors for Hemorrhagic Stroke) Study and the Ethnic/Racial Variations of ICH (ERICH) Study. Cognitive impairment before ICH was defined as positive history of dementia or treatment with donepezil, galantamine, memantine, or rivastigmine on chart abstraction or baseline interview. Specific outcomes—modified Rankin Scale score at 3 months (0–2 versus ≥3), Barthel Index score (<100 versus 100) at 3 months, and withdrawal of care—were analyzed using multivariable logistic regression. Propensity score matching and analysis was done because of imbalances between cognitively impaired and cognitively intact groups. Results: Of the 3537 cases of ICH, 304 patients had cognitive impairment predating ICH. Cognitively impaired subjects were more likely to experience withdrawal of care during hospitalization, and for survivors, greater disability (modified Rankin Scale score of ≥3) and lower Barthel scores after ICH. After propensity score matching, preexisting cognitive impairment was associated with a lower modified Rankin Scale at 3 months in the White, Black, and Hispanic subgroups. Conclusions: Preexisting cognitive impairment was associated with loss of independence 3-month post-ICH, when matching for risk factors of cognitive impairment, in the White, Black, and Hispanic subgroups. This suggests that preexisting cognitive impairment has a negative effect in obtaining functional independence following ICH, irrespective of race/ethnicity.

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Severity assessment in maximally treated ICH patients

Neurology ◽

10.1212/wnl.0000000000004174 ◽

2017 ◽

Vol 89 (5) ◽

pp. 423-431 ◽

Cited By ~ 41

Author(s):

Jochen A. Sembill ◽

Stefan T. Gerner ◽

Bastian Volbers ◽

Tobias Bobinger ◽

Hannes Lücking ◽

...

Keyword(s):

Propensity Score ◽

Functional Outcome ◽

Propensity Score Matching ◽

Scale Score ◽

Predictive Validity ◽

Assessment Tool ◽

Favorable Outcome ◽

Severity Assessment ◽

Poor Outcome ◽

Ich Score

Objective:As common prognostication models in intracerebral hemorrhage (ICH) are developed variably including patients with early (<24 hours) care limitations (ECL), we investigated its interaction with prognostication in maximally treated patients and sought to provide a new unbiased severity assessment tool.Methods:This observational cohort study analyzed consecutive ICH patients (n = 583) from a prospective registry over 5 years. We characterized the influence of ECL on overall outcome by propensity score matching and on conventional prognostication using receiver operating characteristic analyses. We established the max-ICH score based on independent predictors of 12-month functional outcome in maximally treated patients and compared it to existing models.Results:Prevalence of ECL was 19.2% (n = 112/583) and all of these patients died. Yet propensity score matching displayed that 50.7% (n = 35/69) theoretically could have survived, with 18.8% (n = 13/69) possibly reaching favorable outcome (modified Rankin Scale score 0–3). Conventional prognostication seemed to be confounded by ECL, documented by a decreased predictive validity (area under the curve [AUC] 0.67, confidence interval [CI] 0.61–0.73 vs AUC 0.80, CI 0.76–0.83; p < 0.01), overestimating poor outcome (mortality by 44.8%, unfavorable outcome by 10.1%) in maximally treated patients. In these patients, the novel max-ICH score (0–10) integrates strength-adjusted predictors, i.e., NIH Stroke Scale score, age, intraventricular hemorrhage, anticoagulation, and ICH volume (lobar and nonlobar), demonstrating improved predictive accuracy for functional outcome (12 months: AUC 0.81, CI 0.77–0.85; p < 0.01). The max-ICH score may more accurately delineate potentials of aggressive care, showing favorable outcome in 45.4% (n = 214/471) and a long-term mortality rate of only 30.1% (n = 142/471).Conclusions:Care limitations significantly influenced the validity of common prognostication models resulting in overestimation of poor outcome. The max-ICH score demonstrated increased predictive validity with minimized confounding by care limitations, making it a useful tool for severity assessment in ICH patients.

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Influence of Early Enteral Nutrition on Clinical Outcomes in Neurocritical Care Patients With Intracerebral Hemorrhage

Frontiers in Neurology ◽

10.3389/fneur.2021.665791 ◽

2021 ◽

Vol 12 ◽

Author(s):

Jianhua Peng ◽

Bastian Volbers ◽

Maximilian I. Sprügel ◽

Philip Hoelter ◽

Tobias Engelhorn ◽

...

Keyword(s):

Propensity Score ◽

Enteral Nutrition ◽

Intracerebral Hemorrhage ◽

Hospital Stay ◽

Functional Outcome ◽

Clinical Outcomes ◽

Neurocritical Care ◽

Mortality Rates ◽

Early Enteral Nutrition ◽

Current Standard

Objective: Early enteral nutrition (EEN) represents the current standard of care for patients treated in general intensive care units (ICU). Specific nutritional recommendations for patients receiving dedicated neurocritical care are not established. This study investigated associations of EEN with clinical outcomes for patients suffering from intracerebral hemorrhage treated at a neurological ICU (NICU).Methods: This retrospective cohort study included patients admitted to the NICU with atraumatic ICH over a 4-year period. Nutritional data, demographic, clinical, radiological, and laboratory characteristics were assessed. EEN was defined as any enteral nutrition within 48 hours after admission. Comparisons were undertaken for patients with EEN vs. those without, further propensity score (PS) matching (caliper 0.2; one: many) was used to account for baseline imbalances. Primary outcome was the modified Rankin Scale (0–3 = favorable, 4–6 = unfavorable) at 12 months, secondary outcomes comprised perihemorrhagic edema (PHE) volume, infectious complications during the hospital stay, and mRS at 3 months, as well as mortality rates at 3 and 12 months.Results: Of 166 ICH-patients treated at the NICU, 51 (30.7%) patients received EEN, and 115 (69.3%) patients received no EEN (nEEN). After propensity score matching, calories delivered from enteral nutrition (EEN 161.4 [106.4–192.3] kcal/day vs. nEEN 0.0 [0.0–0.0], P < 0.001) and the total calories (EEN 190.0 [126.0–357.0] kcal/day vs. nEEN 33.6 [0.0–190.0] kcal/day, P < 0.001) were significantly different during the first 48 h admitted in NICU. Functional outcome at 12 months (mRS 4–6, EEN 33/43 [76.7%] vs. nEEN, 49/64 [76. 6%]; P = 1.00) was similar in the two groups. There were neither differences in mRS at 3 months, nor in mortality rates at 3 and 12 months between the two groups. EEN did not affect incidence of infective complications or gastrointestinal adverse events during the hospital stay; however, EEN was associated with significantly less extent of PHE evolution [maximum absolute PHE (OR 0.822, 95% CI 0.706–0.957, P = 0.012); maximum relative PHE (OR 0.784, 95% CI 0.646–0.952, P = 0.014)].Conclusion: In our study, EEN was associated with reduced PHE in ICH-patients treated at a NICU. However, this observation did not translate into improved survival or functional outcome at 3 and 12 months.

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Dynamic change of heart rate in the acute phase and clinical outcomes after intracerebral hemorrhage: a cohort study

Journal of Intensive Care ◽

10.1186/s40560-021-00540-0 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Shoujiang You ◽

Yupin Wang ◽

Zian Lu ◽

Dandan Chu ◽

Qiao Han ◽

...

Keyword(s):

Heart Rate ◽

Intracerebral Hemorrhage ◽

Functional Outcome ◽

Scale Score ◽

Acute Phase ◽

Coefficient Of Variation ◽

Dynamic Change ◽

Modified Rankin Scale ◽

Increased Risk ◽

All Cause Mortality

Abstract Background Dynamic change of heart rate in the acute phase and clinical outcomes after intracerebral hemorrhage (ICH) remains unknown. We aimed to investigate the associations of heart rate trajectories and variability with functional outcome and mortality in patients with acute ICH. Methods This prospective study was conducted among 332 patients with acute ICH. Latent mixture modeling was used to identify heart rate trajectories during the first 72 h of hospitalization after ICH onset. Mean and coefficient of variation of heart rate measurements were calculated. The study outcomes included unfavorable functional outcome, ordinal shift of modified Rankin Scale score, and all-cause mortality. Results We identified 3 distinct heart rate trajectory patterns (persistent-high, moderate-stable, and low-stable). During 3-month follow-up, 103 (31.0%) patients had unfavorable functional outcome and 46 (13.9%) patients died. In multivariable-adjusted model, compared with patients in low-stable trajectory, patients in persistent-high trajectory had the highest odds of poor functional outcome (odds ratio 15.06, 95% CI 3.67–61.78). Higher mean and coefficient of variation of heart rate were also associated with increased risk of unfavorable functional outcome (P trend < 0.05), and the corresponding odds ratios (95% CI) comparing two extreme tertiles were 4.69 (2.04–10.75) and 2.43 (1.09–5.39), respectively. Likewise, similar prognostic effects of heart rate dynamic changes on high modified Rankin Scale score and all-cause mortality were observed. Conclusions Persistently high heart rate and higher variability in the acute phase were associated with increased risk of unfavorable functional outcome in patients with acute ICH.

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Blood Pressure and Anticoagulation Reversal Management during Off-Hours in Oral Anticoagulation-Associated Intracerebral Hemorrhage

Cerebrovascular Diseases ◽

10.1159/000507316 ◽

2020 ◽

Vol 49 (2) ◽

pp. 177-184

Author(s):

Anne Mrochen ◽

Maximilian I. Sprügel ◽

Stefan T. Gerner ◽

Jochen A. Sembill ◽

Stefan Lang ◽

...

Keyword(s):

Blood Pressure ◽

Intracerebral Hemorrhage ◽

Functional Outcome ◽

Clinical Outcomes ◽

Vitamin K ◽

Oral Anticoagulation ◽

Secondary Outcome ◽

Anticoagulation Reversal ◽

Anticoagulation Treatment ◽

Hematoma Enlargement

Background: Prevention of hematoma enlargement in oral anticoagulation-associated intracerebral hemorrhage (OAC-ICH) focuses on blood pressure (BP) reduction and OAC reversal. We investigated whether treatment efficiency and clinical outcomes differ between OAC-ICH patients admitted outside versus during regular working hours. Methods: Based on pooled data of multicenter cohort studies, we grouped OAC-ICH patients (vitamin K antagonist [VKA], non-vitamin K oral anticoagulant [NOAC]) according to on- vs. off-hour admission. Primary outcome was the functional outcome using the modified Rankin scale (mRS) dichotomized into favorable (mRS 0–3) and unfavorable (mRS 4–6) and mortality at 3 months. Secondary outcome measures included the occurrence of hematoma enlargement, the proportions of patients with systolic BP <140 mm Hg and with anticoagulation treatment achieving international normalized ratio (INR) levels <1.3 at 4 h. Propensity score matching (PSM) was performed to account for imbalances in baseline characteristics. Results: The study population consisted of 76/126 NOAC-ICH patients and 1,005/1,470 VKA patients presenting during off-hours. Functional outcome and mortality rates were not significantly different among PSM patients with VKA-ICH and NOAC-ICH during on- vs. off-hours (mRS 4–6 VKA-ICH: on-hour: 239/357 [66.9%] vs. 253/363 [69.7%] off-hour; p = 0.43; NOAC-ICH: on-hour 26/42 [61.9%] vs. off-hour: 37/57 [64.9%]; p = 0.76; mRS 6 VKA-ICH: on-hour: 127/357 [35.6%] vs. off-hour: 148/363 [40.8%]; p = 0.15; NOAC-ICH: on-hour 17/42 [40.5%] vs. off-hour: 16/57 [28.1%]; p = 0.20). There were no differences detectable regarding the secondary outcome measures (i.e., hematoma enlargement, the proportion of patients who achieved systolic BP levels <140 mm Hg at 4 h as well as anticoagulation treatment achieving INR levels <1.3 at 4 h) in OAC patients. Conclusion: Our study implies that BP reduction and anticoagulation reversal management are well established and associated with similar rates of hematoma enlargement and clinical outcomes in on- vs. off-hour admitted OAC-ICH patients.

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Age-dependent clinical outcomes in primary versus oral anticoagulation-related intracerebral hemorrhage

International Journal of Stroke ◽

10.1177/1747493019895662 ◽

2019 ◽

pp. 174749301989566 ◽

Cited By ~ 1

Author(s):

Maximilian I Sprügel ◽

Joji B Kuramatsu ◽

Stefan T Gerner ◽

Jochen A Sembill ◽

Dominik Madžar ◽

...

Keyword(s):

Functional Outcome ◽

Clinical Outcomes ◽

Vitamin K ◽

Treatment Strategies ◽

Primary Outcome Measure ◽

Vitamin K Antagonist ◽

Secondary Outcome ◽

Treatment Interventions ◽

Hematoma Enlargement ◽

Age Dependent

Aims This study determined the influence of age on bleeding characteristics and clinical outcomes in primary spontaneous (non-OAC), vitamin K antagonist-related (VKA-) and non-vitamin K antagonist oral anticoagulant-related (NOAC-) ICH. Methods Pooled individual patient data of multicenter cohort studies were analyzed by logistic regression modelling and propensity-score-matching (PSM) to explore the influence of advanced age on clinical outcomes among non-OAC-, VKA-, and NOAC-ICH. Primary outcome measure was functional outcome at three months assessed by the modified Rankin Scale, dichotomized into favorable (mRS = 0–3) and unfavorable (mRS = 4–6) functional outcome. Secondary outcome measures included mortality, hematoma characteristics, and frequency of invasive interventions. Results In VKA-ICH 33.5% (670/2001), in NOAC-ICH 44.2% (69/156) and in non-OAC-ICH 25.2% (254/1009) of the patients were ≥80 years. After adjustment for treatment interventions and relevant parameters, elderly ICH patients comprised worse functional outcome at three months (adjusted odds ratio (aOR) in VKA-ICH: 1.49 (1.21–1.84); p < 0.001; NOAC-ICH: 2.01 (0.95–4.26); p = 0.069; non-OAC-ICH: 3.54 (2.50–5.03); p < 0.001). Anticoagulation was significantly associated with worse functional outcome below the age of 70 years, (aOR: 2.38 (1.78–3.16); p < 0.001), but not in patients of ≥70 years (aOR: 1.21 (0.89–1.65); p = 0.217). The differences in initial ICH volume and extent of ICH enlargement between OAC-ICH and non-OAC-ICH gradually decreased with increasing patient age. Conclusions As compared to elderly ICH-patients, in patients <70 years OAC-ICH showed worse clinical outcomes compared to non-OAC-ICH because of larger baseline ICH-volumes and extent of hematoma enlargement. Treatment strategies aiming at neutralizing altered coagulation should be aware of these findings.

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The SITS Open Study

Stroke ◽

10.1161/strokeaha.120.031031 ◽

2021 ◽

Author(s):

Niaz Ahmed ◽

Kennedy R. Lees ◽

Rudiger von Kummer ◽

Staffan Holmin ◽

Irene Escudero-Martinez ◽

...

Keyword(s):

Clinical Practice ◽

Propensity Score ◽

Propensity Score Matching ◽

Scale Score ◽

Intracranial Hemorrhage ◽

Standard Care ◽

Artery Occlusion ◽

Large Artery ◽

Modified Rankin Scale ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose: We designed SITS (Safe Implementation of Treatment in Stroke) Open to determine benefit and safety of thrombectomy in clinical practice for large artery occlusion stroke, using selected stent retrievers plus standard care versus standard care alone. Methods: SITS Open was a prospective, open, blinded evaluation, international, multicenter, controlled, nonrandomized registry study. Centers lacking access to thrombectomy contributed controls. Primary end point was categorical shift in modified Rankin Scale score at 3 months in the per protocol (PP) population. Principal secondary outcomes were symptomatic intracranial hemorrhage, functional independency (modified Rankin Scale score 0–2) and death at 3 months. Patients independently evaluated by video-recorded modified Rankin Scale interviews blinded to treatment or center identity by central core laboratory were regarded as PP population. Propensity score matching with covariate adjusted analysis was performed. Results: During 2014 to 2017, 293 patients (257 thrombectomy, 36 control) from 26 centers in 10 countries fulfilled intention-to-treat and 200 (170 thrombectomy, 30 control) PP criteria; enrollment of controls was limited by rapid uptake of thrombectomy. In PP analysis, median age was 71 versus 71 years, and baseline National Institutes of Health Stroke Scale 17 versus 17 in the thrombectomy and control arms, respectively. The propensity score matching analysis for PP showed a significant shift for modified Rankin Scale at 3 months favoring the thrombectomy group (odds ratio, 3.8 [95% CI, 1.61–8.95]; P =0.002). Regarding safety, there were 4 cases of symptomatic intracranial hemorrhage in the thrombectomy group (2.4%) and none in the control group. Conclusions: In clinical practice, thrombectomy for patients with large artery occlusion stroke is superior to standard of care in our study. REGISTRATION: URL: https://www.clinicaltrials.gov . Unique Identifier: NCT02326428.

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

Neurocritical Care ◽

10.1007/s12028-021-01229-w ◽

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.

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