Objective: Elevated systolic blood pressure (SBP) after successful revascularization (SR) via endovascular therapy (EVT) is a known predictor of poor outcome. However, the optimal SBP goal following EVT is still unknown. Our objective was to compare functional and safety outcomes between different SBP goals after EVT with SR. Methods: This international multicenter study included 8 comprehensive stroke centers and patients with anterior circulation large vessel occlusion who were treated with EVT and achieved SR. SR was defined as modified thrombolysis in cerebral ischemia 2b to 3. Patients were divided into 3 groups based on SBP goal in the first 24 hours after EVT. Inverse probability of treatment weighting (IPTW) propensity analysis was used to assess the effect of different SBP goals on clinical outcomes. Results: A total of 1,019 patients were included. On IPTW analysis, the SBP goal of <140mmHg was associated with a higher likelihood of good functional outcome and lower odds of hemicraniectomy compared to SBP goal of <180mmHg. Similarly, SBP goal of <160mmHg was associated with lower odds of mortality compared to SBP goal of <180mmHg. In subgroup analysis including only patients with pre-EVT SBP of ≥140mmHg, an SBP of <140mmHg was associated with a higher likelihood of good functional outcome, lower odds of symptomatic intracranial hemorrhage, and lower odds of requirement for hemicraniectomy compared to SBP goal of <180mmHg.View this article online at wileyonlinelibrary.com.

BackgroundElevated systolic blood pressure (SBP) after mechanical thrombectomy (MT) correlates with worse outcome. However, the association between SBP reduction (SBPr) and outcome after successful reperfusion with MT is not well established.ObjectiveTo investigate the association between SBPr in the first 24 hours after successful reperfusion and the functional and safety outcomes of MT.MethodsA multicenter retrospective study, which included 10 comprehensive stroke centers, was carried out. Patients with acute ischemic stroke and anterior circulation large vessel occlusions who achieved successful reperfusion via MT were included. SBPr was calculated using the formula 100×([admission SBP−mean SBP]/admission SBP). Poor outcome was defined as a modified Rankin Scale (mRS) score of 3–6 at 90 days. Safety endpoints included symptomatic intracerebral hemorrhage, mortality, and requirement for hemicraniectomy during admission. A generalized mixed linear model was used to study the association between SBPr and outcomes.ResultsA total of 1361 patients were included in the final analysis. SBPr as a continuous variable was inversely associated with poor outcome (OR=0.97; 95% CI 0.95 to 0.98; p<0.001) but not with the safety outcomes. Subanalysis based on reperfusion status showed that SBPr was associated with lower odds of poor outcome only in patients with complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI 3)) but not in patients with incomplete reperfusion (mTICI 2b). When SBPr was divided into categories (<1%, 1%–10%, 11%–20%, >20%), the rate of poor outcome was highest in the first group.ConclusionSBPr in the first 24 hours after successful reperfusion was inversely associated with poor outcome. No association between SBPr and safety outcome was found.

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Introduction: Hypertension is a known predictor of poor outcome and hemorrhagic complications after ischemic stroke. However, the effect of blood pressure (BP) on outcome of those undergoing mechanical thrombectomy and especially after successful recanalization is not well understood. In this study, we investigated the association between BP parameters and outcome measures after successful recanalization with MT. Methods: This was a retrospective, multicenter study, involving 7 comprehensive stroke centers, of patients with acute ischemic stroke due to large vessel occlusion who achieved successful recanalization with MT. Systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure (MAP) were obtained at frequent intervals (at least hourly) for each patient in the first 24 hours following MT. Outcome measures included 90 day-modified Rankin Scale (mRS), 90-day morality, and symptomatic intracerebral hemorrhage (sICH). Successful recanalization was defined as TICI 2b-3, and sICH as any hemorrhage associated with > 4 points increase in NIHSS. A mixed logistic model was used to identify predictors of functional and hemorrhagic outcomes. Results: A total of 989 patients were included, of whom 453 (45.8%) achieved good outcome, defined as an mRS of 0-2. Mean, and maximum SBP were higher in the poor outcome group (131.6 +15 vs. 127 +14.3; p <0.001, and 166± 24.7 vs. 158±24.3; p<0.001, respectively). There was no significant difference in the rest of BP measurement between the two groups. With respect to hemorrhagic complications, 40 (4.2%) patients develop sICH after MT. SBP, DBP and MAP were higher in sICH group. Table 1 summarizes multivariable analysis results. Conclusion: Higher blood pressure was associated with hemorrhagic complications, and worse functional outcome following successful mechanical thrombectomy.

Background: Advanced cardiac imaging(ACI) with cardiac CT (CCT) and cardiac MR (CMR) are valuable noninvasive investigative tools to assess cardiac structure in cryptogenic stroke assessment. In this study, we examine patient, electrocardiographic (EKG), and TTE variables associated with subsequent detection of intracardiac thrombus using CCT and CMR in patients with cryptogenic stroke. Methods: The Medical University of South Carolina Comprehensive stroke center database was used to identify acute ischemic stroke patients who received inpatient CCT or CMR between January 2017 to May 2018. Patient demographics, past medical history, EKG, and TTE related variables were abstracted by 2 physicians. Univariate and multivariable logistic regression was used to identify factors associated with detection of intracardiac thrombus on CCT/CMR. Negative and positive predictive value (NPV and PPV) were calculated for TTE, with CCT/CMR considered as gold standard. Results: 256 subjects received CCT/CMR after TTE during the study period; with 25 (9.7%) found to have an intracardiac thrombus [12 (4.7%) LV thrombus, 6 (2.3%) LA thrombus, 7 (2.8%) Others including myxoma,valve aortic arch thrombus]. The PPV and NPV of TTE were 57% and 93% respectively. Mild-Modertely Reduced (30-50% EF was associated with subsequent detection of intracardiac thrombus onCCT/CMR in univariate model, but did not reach significance after adjusting for other variables. Atrial fibrillation, P wave abnormality on EKG, ST changes on EKG, Left Ventricle wall motion akinesia on TTE were associated with intracardiac thrombus on CCT/CMR in both models. Conclusion: Advanced cardiac imaging is a useful noninvasive tool to identify cardiac source of ischemic stroke. Although small sample size and inadequate power may limit generalizability, patients with atrial fibrillation, P wave and ST changes on EKG, and LV wall motion akinesis should be considered for advanced cardiac.

Introduction: Previous studies showed that lowering blood pressure in the acute phase after stroke may be harmful. However, the effect of blood pressure lowering on outcome after successful recanalization is not well known. Objective: The aim of this study was to evaluate the association between systolic blood pressure (SBP) reduction and outcome of thrombectomy after successful recanalization. Methods: This was a retrospective multicenter study of patients with anterior circulation large vessel occlusions who achieved successful recanalization (TICI 2b-3) with MT. Degree of SBP reduction was calculated using the following formula: 100*(admission SBP - minimum SBP within 24 hours)/admission SBP. Patients were divided into two groups: group 1) included patients with ≤25% SBP drop; group 2) included patients with > 25% SBP drop. Outcome measures included 90 days mRS, symptomatic ICH (sICH), and mortality Results: Of 991 screened patients, 917 had available admission SBP data. Average age was 68+14 years. The average admission SBP was 143 ±27 mm Hg. 383 (38.6%) patients had less than 25% SBP reduction, whereas 495 (49.9%) had > 25% SBP reduction in the first 24 hrs. There was no difference in the proportion of patients who achieved good outcome (mRS) between the two groups. Likewise there was no difference in the rate of sICH between two groups (4..2% vs. 4.5%;p=0.84). SBP reduction was not significantly associated with functional outcome on multivariate analysis (OR=1.003; 95% CI 0.99-1.013, p=0.54). Conclusion: blood pressure lowering after successful recanalization appears to be safe and was not associated with worse outcome. Further studies are needed to determine whether BP lowering is actually beneficial

Introduction: The incidence and clinical significance of subarachnoid hemorrhage post mechanical thrombectomy (MT) has been evaluated after stent retriever use in limited studies. The goal of this study is to report the incidence, identify predictors of SAH, and explore the effect of SAH on outcome after MT with ADAPT technique. Method: We interrogated our prospectively collected ADAPT database to identify patients who developed SAH post MT. All patients were treated using ADAPT technique. Collected variables included demographics, comorbidities, admission NIHSS, procedural variables and outcome variables. Post procedural CT scans were reviewed by independent Neuroneuro-surgeon to identify SAH. Successful recanalization was defined as mTICI≥ 2b. Outcome measures included 90 days modified Rankin scale (mRS) and mortality. Logistic regression was used to identify the predictors of SAH and explore the effect of SAH on outcome. Results: A total of 510 patients were included in the study. Thirty-three patients (6.4%) had evidence of SAH on the post thrombectomy CT scan. There were more patients with HTN in the SAH group (90.9% vs 73.2%; p=0.024). Adjunctive stent retriever was used more in SAH group (57.6% vs 29.6%; p=0.001). More patients in SAH group required two or more attempts to achieve recanalization (93.9% vs 62.8%; p<0.001). Successful recanalization was achieved in higher proportion of patients in the non-SAH group (93.5% vs 81.8% p=0.012). On multivariate analysis, only HTN (OR 0.29: 95% CI 0.086-0.983) and higher number of aspiration attempts (OR 6.124: 95% CI 1.32-28.25) were associated with SAH .With respect to functional outcome, patients with SAH had worse outcome (mRS 3-6) comparing to non SAH (75.8% vs 55.6%; p= 0.023). However, SAH did not predict poor functional outcome on multivariate analysis. Conclusion: SAH after mechanical thrombectomy is not uncommon. HTN and higher number of attempts were associated with SAH when ADAPT technique was used. The presence of SAH does not appear to predict worse outcome.

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