Association of Personalized Blood Pressure Targets With Hemorrhagic Transformation and Functional Outcome After Endovascular Stroke Therapy

Petersen, Nils; Silverman, Andrew; Wang, Anson; Strander, Sumita; Kodali, Sreeja; Matouk, Charles; Sheth, Kevin N

doi:10.1001/jamaneurol.2019.2120

Cited by 34 publications

(23 citation statements)

References 5 publications

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“…Petersen et al. conducted a study of 65 patients using near infrared spectroscopy to define individual mean arterial pressures that result in optimal cerebral autoregulation after thrombectomy . This study reported an association between time spent with mean arterial pressure above the upper limit of autoregulation and worse functional recovery at discharge and at 90 days, and more haemorrhagic transformation and symptomatic intracranial haemorrhage.…”

Section: Discussionmentioning

confidence: 99%

A pilot randomised controlled trial of the management of systolic blood pressure during endovascular thrombectomy for acute ischaemic stroke

et al. 2019

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Summary It is unknown whether systolic blood pressure augmentation during endovascular thrombectomy improves clinical outcomes. This pilot randomised controlled trial aimed to assess the feasibility of differential systolic blood pressure targeting during endovascular thrombectomy procedures for anterior circulation ischaemic stroke. Fifty‐one eligible patients fulfilling the national criteria for endovascular thrombectomy were randomly assigned to receive either standard or augmented systolic blood pressure management from the start of anaesthesia to recanalisation of the target vessel. Systolic blood pressure targets for the standard and augmented groups were 130–150 mmHg and 160–180 mmHg, respectively. The study achieved all feasibility targets, including a recruitment rate of 3.5 participants per week and median (IQR [range]) of mean systolic blood pressure separation between groups of 139 (135–143 [115–154]) vs. 167 (150–175 [113–188]) mmHg, p < 0.001. Data completeness was 99%. Independent functional recovery at 90 days (modified Rankin Scale 0, 1 or 2) was achieved in 30 (59%) patients, which is consistent with previously published data. There were no safety concerns with trial procedures. In conclusion, a large randomised controlled efficacy trial of standard vs. augmented systolic blood pressure management during endovascular thrombectomy is feasible.

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Section: Discussionmentioning

confidence: 99%

A pilot randomised controlled trial of the management of systolic blood pressure during endovascular thrombectomy for acute ischaemic stroke

et al. 2019

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“…Recent studies have shown that real-time autoregulation monitoring can be used to identify a dynamic BP range in individual patients at which autoregulation is optimally functioning (27)(28)(29)(30)(31). Such an autoregulation-derived, personalized BP range may provide a favorable physiologic landscape for the acutely injured brain.…”

Section: Blood Pressure Management Following Thrombectomymentioning

confidence: 99%

“…Such an autoregulation-derived, personalized BP range may provide a favorable physiologic landscape for the acutely injured brain. Accordingly, the following section will review the use of cerebral autoregulation monitoring in patients with acute ischemic stroke, highlighting the hypothesis that exceeding a personalized upper limit of autoregulation predisposes patients to reperfusion injury and HT (27,29)…”

Section: Blood Pressure Management Following Thrombectomymentioning

confidence: 99%

“…The Cambridge group has been refining this work over several decades, particularly in patients with traumatic brain injury (43). With this hypothesis in mind, a recent study harnessed autoregulation monitoring to identify and track personalized BP limits in 90 patients undergoing EVT for LVO ischemic stroke (27,29). This cohort revealed that continuous estimations of optimal BP and autoregulatory limits are feasible in post-EVT care.…”

Section: Cerebral Autoregulation and Blood Pressure Personalizationmentioning

confidence: 99%

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Hemodynamics and Hemorrhagic Transformation After Endovascular Therapy for Ischemic Stroke

et al. 2020

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Hemorrhagic transformation remains a potentially catastrophic complication of reperfusion therapies for the treatment of large-vessel occlusion ischemic stroke. Observational studies have found an increased risk of hemorrhagic transformation in patients with elevated blood pressure as well as a high degree of blood pressure variability, suggesting a link between hemodynamics and hemorrhagic transformation. Current society-endorsed guidelines recommend maintaining blood pressure below a fixed threshold of 180/105 mmHg regardless of thrombolytic or endovascular intervention. However, given the high recanalization rates with mechanical thrombectomy, it is unclear if the same hemodynamic goals from the pre-thrombectomy era apply. Also, individual patient factors such as the degree of reperfusion, infarct size, and collateral status likely need to be considered. In this review, we will discuss current evidence linking hemodynamics to hemorrhagic transformation after mechanical thrombectomy. In addition, we will review the clinical relevance of cerebral autoregulation in stroke, highlighting recent studies that have harnessed autoregulatory physiology to define and trend individualized limits of autoregulation. This review will go on to emphasize the translatability of this approach to stroke management. Finally, we will discuss novel statistical approaches like trajectory analysis to post-thrombectomy hemodynamics.

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“…Interestingly, the blood vessels on the contralateral side of the ischemia are also dilated in order to perfuse the penumbra through the collateral circulation. Cerebrovascular pressure reactivity and tissue oxygenation measurements using near-infrared spectroscopy have been reported to estimate autoregulation index in stroke patients ( 30 , 31 , 32 ).…”

Section: Hemodynamics and Pathophysiology Of Lvo Strokesmentioning

confidence: 99%

Blood Pressure Management Following Large Vessel Occlusion Strokes: A Narrative Review

Das¹,

John²,

Bokka³

et al. 2020

Balkan Med J

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Stroke is one of the leading causes of morbidity and mortality worldwide. Intravenous tissue plasminogen activator and mechanical thrombectomy comprise the two major treatments for acute ischemic stroke. Tissue plasminogen activator has been used for more than two decades and guidelines for hemodynamic management following tissue plasminogen activator administration are well established. However, mechanical thrombectomy is a relatively newer therapy and there is a paucity of evidence regarding hemodynamic management following large vessel occlusion strokes. The important tenets guiding the pathophysiology of large vessel occlusion strokes include understanding of cerebral autoregulation, collateral circulation, and blood pressure variability. In this narrative review, we discuss the current American Heart Association-American Stroke Association guidelines for the early management of acute ischemic stroke during different phases of the illness, encountered at different sections of a hospital including the emergency room, the neuro-interventional suite, and the intensive care unit. There is emerging evidence with regard to post-recanalization blood pressure management following large vessel occlusion strokes. Future research directions will include real-time blood pressure variability assessments, identifying the extent of impaired autoregulation, and providing guidelines related to range and personalized blood pressure trajectories for patients following large vessel occlusion strokes.

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Association of Personalized Blood Pressure Targets With Hemorrhagic Transformation and Functional Outcome After Endovascular Stroke Therapy

Cited by 34 publications

References 5 publications

A pilot randomised controlled trial of the management of systolic blood pressure during endovascular thrombectomy for acute ischaemic stroke

A pilot randomised controlled trial of the management of systolic blood pressure during endovascular thrombectomy for acute ischaemic stroke

Hemodynamics and Hemorrhagic Transformation After Endovascular Therapy for Ischemic Stroke

Blood Pressure Management Following Large Vessel Occlusion Strokes: A Narrative Review

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