Decreases in Blood Pressure During Thrombectomy Are Associated With Larger Infarct Volumes and Worse Functional Outcome

Abstract

Background and Purpose— After large-vessel intracranial occlusion, the fate of the ischemic penumbra, and ultimately final infarct volume, largely depends on tissue perfusion. In this study, we evaluated whether blood pressure reduction and sustained relative hypotension during endovascular thrombectomy are associated with infarct progression and functional outcome. Methods— We identified consecutive patients with large-vessel intracranial occlusion ischemic stroke who underwent mechanical thrombectomy at 2 comprehensive stroke centers. Intraprocedural mean arterial pressure (MAP) was monitored throughout the procedure. ΔMAP was calculated as the difference between admission MAP and lowest MAP during endovascular thrombectomy until recanalization. Sustained hypotension was measured as the area between admission MAP and continuous measurements of intraprocedural MAP (aMAP). Final infarct volume was measured using magnetic resonance imaging at 24 hours, and functional outcome was assessed using the modified Rankin Scale at discharge and 90 days. Associations with outcome were analyzed using linear and ordinal multivariable logistic regression. Results— Three hundred ninety patients (mean age 71±14 years, mean National Institutes of Health Stroke Scale score of 17) were included in the study; of these, 280 (72%) achieved Thrombolysis in Cerebral Infarction 2B/3 reperfusion. Eighty-seven percent of patients experienced MAP reductions during endovascular thrombectomy (mean 31±20 mm Hg). ΔMAP was associated with greater infarct growth ( P =0.036) and final infarct volume ( P =0.035). Mean ΔMAP among patients with favorable outcomes (modified Rankin Scale score, 0–2) was 20±21 mm Hg compared with 30±24 mm Hg among patients with poor outcome ( P =0.002). In the multivariable analysis, ΔMAP was independently associated with higher (worse) modified Rankin Scale scores at discharge (adjusted odds ratio per 10 mm Hg, 1.17; 95% CI, 1.04–1.32; P =0.009) and at 90 days (adjusted odds ratio per 10 mm Hg, 1.22; 95% CI, 1.07–1.38; P =0.003). The association between aMAP and outcome was also significant at discharge ( P =0.002) and 90 days ( P =0.001). Conclusions— Blood pressure reduction before recanalization is associated with larger infarct volumes and worse functional outcomes for patients affected by large-vessel intracranial occlusion stroke. These results underscore the importance of BP management during endovascular thrombectomy and highlight the need for further investigation of blood pressure management after large-vessel intracranial occlusion stroke.

A 10% blood pressure drop from baseline during mechanical thrombectomy for stroke is strongly associated with worse neurological outcomes

“…Indeed, previous studies have focused more on absolute hypotension threshold during MT, independently of the time component (ie, MAP drops, SBP drops, etc). Recently, Peterson et al 13 showed an association between hypotension, functional outcomes and infarct growth. Taken together and with our results, it seems that the linear relationship between hypotension time and worse functional outcomes is largely driven by the likely modification of a slow progressor profile (1 mL per hour) into an intermediate progressor (3–10 mL per hour), or a fast progressor (>50 mL) 31 32.…”

“…However, this threshold comes from exclusion criteria of intravenous thrombolysis trials and randomized controlled trials are still lacking to substantiate this position in the setting of LVO. Indeed, decreases in BP below certain thresholds before recanalization (ie, mean arterial pressure (MAP) <70 or 85 mmHg before reperfusion,13–15systolic blood pressure (SBP) <140 mmHg),16 reductions in BP of different magnitudes (≥10% or 40% MAP drop from baseline14 17) and BP variability18 19 have all been associated with worse functional outcomes 15. However, it still remains unclear whether the relationship between the duration of arterial hypotension during MT and the functional outcome is linear and if this relationship is the same under GA and CS.…”

Profound Hypotension before Aortic Clamping Can Exacerbate Spinal Cord Ischemic Injury after Aortic Surgery in Rats

“…Similarly, in a rat model of middle cerebral artery occlusion, deliberate hypotension significantly increased cerebral infarct zone size, irrespective of the hypotensive regimen [13]. Blood pressure reduction before recanalization is associated with aggravated ischemic injury in patients with cerebral infarct [18,19].…”

Blood Pressure During Endovascular Treatment Under Conscious Sedation or Local Anesthesia

“…3,4 Previous studies in patients receiving GA during EVT reported worse outcomes in patients who experienced blood pressure drops during the procedure. [5][6][7][8][9] The administration of anesthetic and analgesic agents may cause gradual or sudden declines in blood pressure. This potentially impairs penumbra perfusion before recanalization.…”