Blood PREssure Augmentation in Large-vessel Occlusion Stroke Study

2020 ◽  
Author(s):  
Keyword(s):  
Blood Pressure ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stroke Study

Abstract WP367: Effect of Early Blood Pressure Reduction on Infarct Size in Patients With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
David Baker ◽  
Dinesh Jillella ◽  
Takashi Shimoyama ◽  
Ken Uchino
Keyword(s):  
Magnetic Resonance Imaging ◽  
Blood Pressure ◽  
Infarct Size ◽  
Collateral Circulation ◽  
Infarct Volume ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Resonance Imaging ◽  
Vessel Occlusion ◽  
Significant Drop

Introduction: In patients with large vessel occlusion presenting with acute ischemic stroke, cerebral perfusion is a major determinant of stroke severity. However, limited data exists to guide hemodynamic management of these patients early after presentation. In this study, we aim to evaluate the effect of blood pressure reductions during the hyper-acute period on infarct size. Methods: From a clinical stroke registry at a single comprehensive stroke center, we reviewed patients with middle cerebral artery (M1) or internal carotid artery occlusion who underwent hyperacute magnetic resonance imaging (MRI) for endovascular treatment decision in 2018. Infarct volume was determined by area of reduced apparent diffusion coefficient using RAPID software. Collateral circulation was scored based on baseline CT angiogram (good collaterals constituted >50% filling, poor collaterals ≤50% filling). Average mean arterial pressure (MAP) readings from the first hour of presentation were compared to average MAP readings from the hour prior to magnetic resonance imaging. For the purposes of our study, a drop of > 20% in the average MAP was regarded as a significant decrease. We hypothesized that both significant drop in MAP and the presence of good collateral circulation were independent predictors of infarct volume expressed as a logarithmic value in multivariable regression model. Results: Of the 35 patients (mean age 67, mean NIHSS 16) meeting inclusion criteria, 11% of patients experienced an early significant drop in MAP prior to time of MRI. Among patients with a significant drop in MAP, the average decrease was 35 mm Hg ±3.3 among those with significant drop from a baseline mean MAP of 125 mm Hg. In the multivariable analysis adjusting for collateral status, a significant drop in average MAP was independently associated with an increase in infarct volume (β = -0.727, p=0.0306). Collateral status also independently predicted infarct size (β=0.775, p=0.0007). Conclusion: Among ischemic stroke patients with large vessel occlusion, a >20% drop in MAP during the hyper-acute period is associated with larger infarct volumes. Further studies are needed to optimize early blood pressure management in these patients.

scholarly journals Effect of short-term blood pressure variability on functional outcome after intra-arterial treatment in acute stroke patients with large-vessel occlusion

2019 ◽  
Author(s):  
Tianli Zhang ◽  
Xiaolong Wang ◽  
Chao Wen ◽  
Feng Zhou ◽  
Shengwei Gao ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Pressure Variability ◽  
Area Under The Curve ◽  
Functional Independence ◽  
Large Vessel ◽  
Multivariable Logistic Regression Analysis ◽  
Large Vessel Occlusion ◽  
Short Term ◽  
Vessel Occlusion ◽  
Blood Pressures

Abstract Background: Endovascular treatment (EVT) is advocated for acute ischemic stroke with large-vessel occlusion (LVO), but perioperative periods are challenging.This study investigated the relationship between post-EVT short-term blood pressure variability (BPV) and early outcomes in LVO patients. Methods: We retrospectively reviewed 72 LVO patients undergoing EVT between June 2015 and June 2018. Hourly systolic and diastolic blood pressures (SBP and DBP, respectively) were recorded in the first 24 hours post-EVT. BPV were evaluated as standard deviation (SD), coefficient of variation (CV), and successive variation (SV) separately for SBP and DBP. Three-month functional independence was defined as a modified Rankin Scale (mRS) score of 0-2. Results: For 58.3% patients with favorable outcomes, median National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT scores on admission were 14 and 8, respectively. The maximum SBP ([154.3±16.8] vs. [163.5±15.6], P=0.02), systolic CV ([8. 8%±2.0%] vs. [11.0%±1.8%], P<0.001), SV ([11.4±2.3] vs. [14.6±2.0], P<0.001), and SD ([10.5±2.4] vs. [13.8±3.9], P<0.001) were lower in patients with favorable outcomes. On multivariable logistic regression analysis, systolic SV (OR: 4.273, 95% CI: 1.030 to 17.727, P=0.045) independently predicted unfavorable prognosis. The area under the curve was 0.868 (95% CI: 0.781 to 0.955, P<0.001), and sensitivity and specificity were 93.3% and 73.8%, respectively, showing excellent value for 3-month poor-outcome predictions. Conclusions: Decreased systolic SV following intra-arterial therapies result in favorable 3-month outcomes. Systolic SV may be a novel predictor of functional prognosis in LVO patients.

scholarly journals Detection of large vessel occlusion stroke with electroencephalography in the emergency room: first results of the ELECTRA-STROKE study

2021 ◽  
Author(s):  
Laura C. C. van Meenen ◽  
Maritta N. van Stigt ◽  
Henk A. Marquering ◽  
Charles B. L. M. Majoie ◽  
Yvo B. W. E. M. Roos ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Data Quality ◽  
Emergency Room ◽  
Prehospital Setting ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stroke Study ◽  
Dry Electrode ◽  
Eeg Data

Abstract Background Prehospital detection of large vessel occlusion stroke of the anterior circulation (LVO-a) would enable direct transportation of these patients to an endovascular thrombectomy (EVT) capable hospital. The ongoing ELECTRA-STROKE study investigates the diagnostic accuracy of dry electrode electroencephalography (EEG) for LVO-a stroke in the prehospital setting. To determine which EEG features are most useful for this purpose and assess EEG data quality, EEG recordings are also performed in the emergency room (ER). Here, we report data of the first 100 patients included in the ER. Methods Patients presented to the ER with a suspected stroke or known LVO-a stroke underwent a single EEG prior to EVT. Diagnostic accuracy for LVO-a stroke of frequency band power, brain symmetry and phase synchronization measures were evaluated by calculating receiver operating characteristic curves. Optimal cut-offs were determined as the highest sensitivity at a specificity of ≥ 80%. Results EEG data were of sufficient quality for analysis in 65/100 included patients. Of these, 35/65 (54%) had an acute ischemic stroke, of whom 9/65 (14%) had an LVO-a stroke. Median onset-to-EEG-time was 266 min (IQR 121–655) and median EEG-recording-time was 3 min (IQR 3–5). The EEG feature with the highest diagnostic accuracy for LVO-a stroke was theta–alpha ratio (AUC 0.83; sensitivity 75%; specificity 81%). Combined, weighted phase lag index and relative theta power best identified LVO-a stroke (sensitivity 100%; specificity 84%). Conclusion Dry electrode EEG is a promising tool for LVO-a stroke detection, but data quality needs to be improved and validation in the prehospital setting is necessary. (TRN: NCT03699397, registered October 9 2018).

scholarly journals Hemodynamics of Leptomeningeal Collaterals after Large Vessel Occlusion and Blood Pressure Management with Endovascular Treatment

2021 ◽  
Vol 23 (3) ◽  
pp. 343-357
Author(s):  
Beom Joon Kim ◽  
Nishita Singh ◽  
Bijoy K. Menon
Keyword(s):  
Blood Pressure ◽  
Blood Flow ◽  
Endovascular Treatment ◽  
Critical Role ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Pial Arteries ◽  
Research Perspectives

Endovascular therapy (EVT) is an effective treatment for ischemic stroke due to large vessel occlusion (LVO). Unlike intravenous thrombolysis, EVT enables visualization of the restoration of blood flow, also known as successful reperfusion in real time. However, until successful reperfusion is achieved, the survival of the ischemic brain is mainly dependent on blood flow from the leptomeningeal collaterals (LMC). It plays a critical role in maintaining tissue perfusion after LVO via pre-existing channels between the arborizing pial small arteries or arterioles overlying the cerebral hemispheres. In the ischemic territory where the physiologic cerebral autoregulation is impaired and the pial arteries are maximally dilated within their capacity, the direction and amount of LMC perfusion rely on the systemic perfusion, which can be estimated by measuring blood pressure (BP). After the EVT procedure, treatment focuses on mitigating the risk of hemorrhagic transformation, potentially via BP reduction. Thus, BP management may be a key component of acute care for patients with LVO stroke. However, the guidelines on BP management during and after EVT are limited, mostly due to the scarcity of high-level evidence on this issue. In this review, we aim to summarize the anatomical and physiological characteristics of LMC to maintain cerebral perfusion after acute LVO, along with a landscape summary of the literature on BP management in endovascular treatment. The objective of this review is to describe the mechanistic association between systemic BP and collateral perfusion after LVO and thus provide clinical and research perspectives on this topic.

scholarly journals Effect of short-term blood pressure variability on functional outcome after intra-arterial treatment in acute stroke patients with large-vessel occlusion

BMC Neurology ◽  
2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Tianli Zhang ◽  
Xiaolong Wang ◽  
Chao Wen ◽  
Feng Zhou ◽  
Shengwei Gao ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Pressure Variability ◽  
Area Under The Curve ◽  
Functional Independence ◽  
Large Vessel ◽  
Multivariable Logistic Regression Analysis ◽  
Large Vessel Occlusion ◽  
Short Term ◽  
Vessel Occlusion ◽  
Poor Outcomes

Abstract Background Endovascular treatment (EVT) is advocated for acute ischaemic stroke with large-vessel occlusion (LVO), but perioperative periods are challenging. This study investigated the relationship between post-EVT short-term blood pressure variability (BPV) and early outcomes in LVO patients. Methods We retrospectively reviewed 72 LVO patients undergoing EVT between June 2015 and June 2018. Hourly systolic and diastolic blood pressures (SBP and DBP, respectively) were recorded in the first 24 h post-EVT. BPV were evaluated as standard deviation (SD), coefficient of variation (CV), and successive variation (SV) separately for SBP and DBP. Functional independence at 3 months was defined as a modified Rankin Scale (mRS) score of 0–2. Results For 58.3% patients with favorable outcomes, the median National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT scores on admission were 14 and 8, respectively. The maximum SBP ([154.3 ± 16.8] vs. [163.5 ± 15.6], P = 0.02), systolic CV ([8. 8% ± 2.0%] vs. [11.0% ± 1.8], P < 0.001), SV ([11.4 ± 2.3] vs. [14.6 ± 2.0], P < 0.001), and SD ([10.5 ± 2.4] vs. [13.8 ± 3.9], P < 0.001) were lower in patients with favorable outcomes. On multivariable logistic regression analysis, systolic SV (OR: 4.273, 95% CI: 1.030 to 17.727, P = 0.045) independently predicted unfavorable prognosis. The area under the curve was 0.868 (95% CI: 0.781 to 0.955, P < 0.001), and sensitivity and specificity were 93.3% and 73.8%, respectively, showing excellent predictive value for 3-month poor-outcomes. Conclusions Decreased systolic SV following intra-arterial therapies result in favorable outcomes at 3 months. Systolic SV may be a novel predictor of functional prognosis in LVO patients.

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.

scholarly journals A Prospective Study to Investigate Controlling Blood Pressure Under Transcranial Doppler After Endovascular Treatment in Patients With Occlusion of Anterior Circulation

2021 ◽  
Vol 12 ◽  
Author(s):  
Chunrong Tao ◽  
Pengfei Xu ◽  
Yang Yao ◽  
Yajuan Zhu ◽  
Rui Li ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Prospective Study ◽  
Transcranial Doppler ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
A Prospective Study

Objective: The objective of this study was to evaluate the effect of blood pressure (BP) management with transcranial Doppler (TCD) guidance in patients with large-vessel occlusion in the anterior circulation after endovascular thrombectomy (EVT) on the long-term prognosis.Methods: This was a prospective study; 232 patients were nonrandomized assigned to TCD-guided BP management (TBM) group or non-TCD-guided BP management (NBM) group. In the TBM group, BP was controlled according to TCD showing cerebral blood flow fluctuation. In the NBM group, BP was controlled according to the guidelines. The primary endpoint was a modified Rankin scale (mRS) score of 2 or lower at 90 days. The safety outcomes were the rates of symptomatic or any intracerebral hemorrhage (ICH) and mortality at 90 days.Results: One hundred sixty-three patients were assigned to the TBM group, and 69 were assigned to the NBM group. In the propensity score-matched cohort (65 matches in both groups), there was significant difference in the proportion of participants with mRS 0–2 at 90 days according to BP management (adjusted odds ratio 3.34, 95% CI 1.36 to 8.22). There was no difference in the rates of symptomatic or any ICH and mortality between two groups. In inverse probability-weighted regression adjustment analysis, mortality decreased significantly in the TBM group than in the NBM group (adjusted odds ratio 0.86, 95% CI 0.76–0.99, p = 0.03).Conclusion: In patients with acute ischemic stroke from large-vessel occlusion in the anterior circulation, BP management under TCD was superior to NBM in improving the clinical outcomes at 90 days.Clinical Trial Registration: (URL: https://www.chictr.org.cn/showproj.aspx?proj=55484; Identifier: ChiCTR2000034443.

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