Higher Blood Pressure during Endovascular Thrombectomy in Anterior Circulation Stroke Is Associated with Better Outcomes
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Background and Purpose Reports investigating the relationship between in-procedure blood pressure (BP) and outcomes in patients undergoing endovascular thrombectomy (EVT) due to anterior circulation stroke are sparse and contradictory. Methods Consecutive EVT-treated adults (modern stent retrievers, BP managed in line with the recommendations, general anesthesia, invasive BP measurements) were evaluated for associations of the rate of in-procedure systolic BP (SBP) and mean arterial pressure (MAP) excursions to >120%/<80% of the reference values (serial measurements at anesthesia induction) and of the reference BP/weighted in-procedure mean BP with post-procedure imaging outcomes (ischemic lesion volume [ILV], hemorrhages) and 3-month functional outcome (modified Rankin Scale [mRS], score 0 to 2 vs. 3 to 6). Results Overall 164 patients (70.7% pharmacological reperfusion, 80.5% with good collaterals, 73.8% with successful reperfusion) were evaluated for ILV (range, 0 to 581 cm3) and hemorrhages (incidence 17.7%). Higher rate of in-procedure SBP/MAP excursions to >120% was independently associated with lower ILV, while higher in-procedure mean SBP/MAP was associated with lower odds of hemorrhages. mRS 0-2 was achieved in 75/155 (48.4%) evaluated patients (nine had missing mRS data). Higher rate of SBP/MAP excursions to >120% and higher reference SBP/MAP were independently associated with higher odds of mRS 0-2, while higher ILV was associated with lower odds of mRS 0-2. Rate of SBP/MAP excursions to <80% was not associated with any outcome. Conclusions In the EVT-treated patients with BP managed within the recommended limits, a better functional outcome might be achieved by targeting in-procedure BP that exceeds the preprocedure values by more than 20%.
Abstract
Background and Purpose Reports investigating the relationship between in-procedure blood pressure (BP) and outcomes in patients undergoing endovascular thrombectomy (EVT) due to anterior circulation stroke are sparse and contradictory. Methods Consecutive EVT-treated adults (modern stent retrievers, BP managed in line with the recommendations, general anesthesia, invasive BP measurements) were evaluated for associations of the rate of in-procedure systolic BP (SBP) and mean arterial pressure (MAP) excursions to >120%/<80% of the reference values (serial measurements at anesthesia induction) and of the reference BP/weighted in-procedure mean BP with post-procedure imaging outcomes (ischemic lesion volume [ILV], hemorrhages) and 3-month functional outcome (modified Rankin Scale [mRS], score 0 to 2 vs. 3 to 6). Results Overall 164 patients (70.7% pharmacological reperfusion, 80.5% with good collaterals, 73.8% with successful reperfusion) were evaluated for ILV (range, 0 to 581 cm3) and hemorrhages (incidence 17.7%). Higher rate of in-procedure SBP/MAP excursions to >120% was independently associated with lower ILV, while higher in-procedure mean SBP/MAP was associated with lower odds of hemorrhages. mRS 0-2 was achieved in 75/155 (48.4%) evaluated patients (nine had missing mRS data). Higher rate of SBP/MAP excursions to >120% and higher reference SBP/MAP were independently associated with higher odds of mRS 0-2, while higher ILV was associated with lower odds of mRS 0-2. Rate of SBP/MAP excursions to <80% was not associated with any outcome. Conclusions In the EVT-treated patients with BP managed within the recommended limits, a better functional outcome might be achieved by targeting in-procedure BP that exceeds the preprocedure values by more than 20%.
참고문헌 (22)
- National Institute of Neurological Disorders, "Tissue plasminogen activator for acute ischemic stroke", N Engl J Med, 333, pp.1581~1587 (1995)
- Hacke W, "Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke", N Engl J Med, 359, pp.1317~1329 (2008)
- Berkhemer OA, "A randomized trial of intraarterial treatment for acute ischemic stroke", N Engl J Med, 372, pp.11~20 (2015)
- Powers WJ, "2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association", American Stroke Association, 2018, pp.49, e46~e110
- Strandgaard S, "Autoregulation of cerebral blood flow in hypertensive patients. The modifying influence of prolonged antihypertensive treatment on the tolerance to acute, druginduced hypotension", Circulation, 53, pp.720~727 (1976)
- Strandgaard S, "Autoregulation of brain circulation in severe arterial hypertension", Br Med J, 1, pp.507~510 (1973)
- Dirnagl U, "Autoregulation of cerebral blood flow in experimental focal brain ischemia", J Cereb Blood Flow Metab, 10, pp.327~336 (1990)
- Mistry EA, "Systolic blood pressure within 24 hours after thrombectomy for acute ischemic stroke correlates with outcome", J Am Heart Assoc, 6, pp.e006167~ (2017)
- Bennett AE, "Increased blood pressure variability after endovascular thrombectomy for acute stroke is associated with worse clinical outcome", J Neurointerv Surg, 10, pp.823~827 (2018)
- Castillo J, "Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome", Stroke, 35, pp.520~526 (2004)
- Grabska K, "Pulse pressure: independent predictor of poor early outcome and mortality following ischemic stroke", Cerebrovasc Dis, 27, pp.187~192 (2009)
- Leonardi-Bee J, "Blood pressure and clinical outcomes in the International Stroke Trial", Stroke, 33, pp.1315~1320 (2002)
- John S, "Lower intraprocedural systolic blood pressure predicts good outcome in patients undergoing endovascular therapy for acute ischemic stroke", Interv Neurol, 4, pp.151~157 (2016)
- Lowhagen Henden P, "Hypotension during endovascular treatment of ischemic stroke is a risk factor for poor neurological outcome", Stroke, 46, pp.2678~2680 (2015)
- Treurniet KM, "A decrease in blood pressure is associated with unfavorable outcome in patients undergoing thrombectomy under general anesthesia", J Neurointerv Surg, 10, pp.107~111 (2018)
- Whalin MK, "Even small decreases in blood pressure during conscious sedation affect clinical outcome after stroke thrombectomy: an analysis of hemodynamic thresholds", AJNR Am J Neuroradiol, 38, pp.294~298 (2017)
- Wahlgren N, "Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study", Lancet, 369, pp.275~282 (2007)
- Adams HP Jr, "Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment", Stroke, 24, pp.35~41 (1993)
- Pikija S, "Fibrinogen consumption is related to intracranial clot burden in acute ischemic stroke: a retrospective hyperdense artery study", J Transl Med, 14, pp.250~ (2016)
- John S, "Timeline of blood pressure changes after intra-arterial therapy for acute ischemic stroke based on recanalization status", J Neurointerv Surg, 9, pp.455~458 (2017)
- Preacher KJ, "SPSS and SAS procedures for estimating indirect effects in simple mediation models", Behav Res Methods Instrum Comput, 36, pp.717~731 (2004)
- Goyal N, "Blood pressure levels post mechanical thrombectomy and outcomes in large vessel occlusion strokes", Neurology, 89, pp.540~547 (2017)