Blood pressure variability and outcomes after mechanical thrombectomy based on the recanalization and collateral status

Li²,

et al. 2021

Front. Aging Neurosci.

Cerebral edema (CDE) is a common complication in patients with acute ischemic stroke (AIS) and can reduce the benefit of endovascular therapy (EVT). To determine whether certain risk factors are associated with a poor prognosis mediated by CDE after EVT. The 759 patients with anterior circulation stroke treated by EVT at three comprehensive stroke centers in China from January 2014 to October 2020 were analyzed. Patients underwent follow-up for 3 months after inclusion. The primary endpoint was a measure of a poor prognosis (modified Rankin Scale score ≥ 3) at 3 months assessed in all patients receiving EVT. Least absolute shrinkage and selection operator and multivariate logistic regression were used to select variables for the prognostic nomogram. Based on these variables, the nomogram was established and validated. In addition, structural equation modeling was used to explore the pathways linking CDE and a poor prognosis. Seven predictors were identified, namely, diabetes, age, baseline Alberta Stroke Program Early CT score, modified Thrombolysis in Cerebral Infarction score, early angiogenic CDE, National Institutes of Health Stroke Scale score, and collateral circulation. The nomogram consisting of these variables showed the best performance, with a large area under the curve in both the internal validation set (0.850; sensitivity, 0.737; specificity, 0.887) and external validation set (0.875; sensitivity, 0.752; specificity, 0.878). In addition, CDE (total path coefficient = 0.24, P < 0.001) served as a significant moderator. A nomogram for predicting a poor prognosis after EVT in AIS patients was established and validated with CDE as a moderator.

Section: Methodsmentioning

confidence: 99%

A Dynamic Nomogram for 3-Month Prognosis for Acute Ischemic Stroke Patients After Endovascular Therapy: A Pooled Analysis in Southern China

Li²,

et al. 2021

Front. Aging Neurosci.

“…In a post-hoc analysis of the BEST study, patients were stratified by recanalization status (TICI 0-2a, 2b, and 3), and high BPV was associated with poor outcomes for patients with TICI 3 exclusively (37). Similarly, another study showed that the effects of higher BPV on outcomes were more pronounced among patients with better reperfusion status (52). A link between higher BP variability and an increased risk of reperfusion injury is supported by Kim et al They found that high BP variability in the first 24 h following successful EVT was associated with an increased risk of symptomatic intracerebral hemorrhage (53).…”

Section: Relevant Observational Studiesmentioning

confidence: 99%

“…Shortterm BP variability has traditionally been measured as minute-tominute or hour-to-hour oscillations. It requires a minimum 24-h period, which limits its usefulness for bedside clinical decision making (29,(51)(52)(53). One promising approach that warrants further investigation is the use of spectral analysis of beat-tobeat blood pressure to detect harmful patterns of BP variability within minutes (60).…”

Section: Future Directionsmentioning

confidence: 99%

Blood Pressure Management After Endovascular Thrombectomy

et al. 2021

Endovascular thrombectomy (EVT) has changed the landscape of acute stroke therapy and has become the standard of care for selected patients presenting with anterior circulation large-vessel occlusion (LVO) stroke. Despite successful reperfusion, many patients with LVO stroke do not regain functional independence. Particularly, patients presenting with extremes of blood pressure (BP) or hemodynamic variability are found to have a worse clinical recovery, suggesting blood pressure optimization as a potential neuroprotective strategy. Current guidelines acknowledge the lack of randomized trials to evaluate the optimal hemodynamic management during the immediate post-stroke period. Following reperfusion, lower blood pressure targets may be warranted to prevent reperfusion injury and promote penumbral recovery, but adequate BP targets adjusted to individual patient factors such as degree of reperfusion, infarct size, and overall hemodynamic status remain undefined. This narrative review outlines the physiological mechanisms of BP control after EVT and summarizes key observational studies and clinical trials evaluating post-EVT BP targets. It also discusses novel treatment strategies and areas of future research that could aid in the determination of the optimal post-EVT blood pressure.

“…3 5 24 25 Additionally, collateral status has also been suggested to affect the association of SBP parameters and outcomes. 24 In our study, we adjusted our logistic regression models for reperfusion grade. We did not adjust for collateral score, as there was a high number of missing data for this variable (50%).…”

Section: Open Accessmentioning

confidence: 99%

Association between systolic blood pressure course and outcomes after stroke thrombectomy

et al. 2021

BackgroundSystolic blood pressure (SBP) after endovascular thrombectomy (EVT) for large artery occlusive stroke is dynamic, requiring adaptable early prediction tools for improving outcomes. We investigated if post-EVT SBP course was associated with outcomes.MethodsEVT-treated patients who had a stroke at Karolinska University Hospital, Stockholm, Sweden, were included in the study during 12 February 2018–11 February 2020. SBP was recorded during the first 24 hours after EVT. Primary outcome was functional independence defined by a Modified Rankin Scale score of 0–2 at 3 months. Secondary outcomes were death by 3 months, symptomatic intracranial haemorrhage and any intracranial haemorrhage. Patients with favourable outcomes were used as a reference SBP course in mixed linear effects models and compared with SBP courses of patients with unfavourable outcomes using the empirical best linear unbiased predictor, measuring deviations from the reference SBP course using the random effects. We tested model predictive stability for SBP measurements of only 18, 12 or 6 hours after EVT.Results374 patients were registered, with mean age 71, median NIHSS score of 15, and 53.2% men. Deviating from a linear SBP course starting at 130 mm Hg and decreasing to 123 mm Hg at 24 hours after EVT was associated with lower chances of functional independence (adjusted OR 0.53, 95% CI 0.29 to 0.88, for reaching either 99 or 147 mm Hg at 24 hours after EVT). All SBP course models for the remaining outcomes did not show statistical significance. Functional independence models showed stable predictive values for all time periods.ConclusionDeviating from a linear SBP course was associated with lower chances of 3-month functional independence.