E-014 Management of Blood Pressure for Acute Ischemic Stroke in the Modern Era of Mechanical Thrombectomy

Mannava, Sishir; Garg, Ankur

doi:10.1136/neurintsurg-2016-012589.86

Electronic Poster Abstracts 2016

DOI: 10.1136/neurintsurg-2016-012589.86

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E-014 Management of Blood Pressure for Acute Ischemic Stroke in the Modern Era of Mechanical Thrombectomy

Sishir Mannava

Ankur Garg

Abstract: thrombolysis in one patient (3%). Successful revascularization was achieved in 31 patients (94%), including TICI III in 16 patients (48.5%). The average number of passes to reperfusion was 1.6 (95% CI 1.3-2.0). Mean time to reperfusion was 47 minutes. Symptomatic intraparenchymal hemorrhage following reperfusion occurred in 2 patients (6%). Procedural complications occurred in 4 patients (12%), including dissection, microwire perforation, and hemorrhage into a pre-existing intracranial tumor; all complications… Show more

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Are Postprocedural Blood Pressure Goals Associated With Clinical Outcome After Mechanical Thrombectomy for Acute Ischemic Stroke?

Blech

Chong²,

Sands

et al. 2019

The Neurologist

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Mechanical thrombectomy (MT) is the standard of care for patients who present with an acute ischemic stroke within 6 hours of symptom onset, and up to 24 hours in appropriately selected patients. However, optimal postoperative management of these patients remains uncertain, especially with regard to blood pressure control. To review the existing literature to define potential blood pressure goals in the immediate postoperative period in patients who undergo MT for acute ischemic stroke. The topic was defined through a clinical scenario and the subsequent development of a targeted clinical question. A literature search was performed, with relevant articles selected, one of which, a prospective observational study, was critically appraised. Participants included neurology residents and consultants, a medical librarian, clinical epidemiologists, as well as content experts from vascular neurology and interventional neuroradiology. Permissive hypertension (defined as <220/120 or <180/105 mm Hg as per the American Heart Association/American Stroke Association guidelines) may be harmful in the postoperative period following MT, especially in patients who were successfully recanalized. Moderate blood pressure control (<160/90) was found to be a predictor of improved 3-month mortality on multivariable logistic regression analysis in patients who sustained successful reperfusion [odds ratio (OR), 0.08; 95% confidence interval (CI), 0.01-0.054; P=0.01]. A 10 mm Hg increase in systolic blood pressure was found to result in a lower OR of having a favorable 3-month functional independence (OR, 0.70; 95% CI, 0.56-0.85; P=0.001) as well as higher rates of 3-month mortality (OR, 1.49; 95% CI, 1.18-1.88; P=0.001). Blood pressure goals in the immediate postoperative period in patients who undergo MT should differ than those who do not undergo MT, with data suggesting that lower blood pressure than permissive hypertension may be related to improved outcomes, especially in cases of successful reperfusion. However, current data are derived from observational studies; further studies, preferably in the form of randomized-controlled trials, are needed to further clarify the relationship between postoperative blood pressures and outcomes in this patient population.

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Are Postprocedural Blood Pressure Goals Associated With Clinical Outcome After Mechanical Thrombectomy for Acute Ischemic Stroke?

Blech

Chong²,

Sands

et al. 2019

The Neurologist

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Fixed Compared With Autoregulation-Oriented Blood Pressure Thresholds After Mechanical Thrombectomy for Ischemic Stroke

Petersen

Silverman

Strander

et al. 2020

Stroke

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Background and Purpose— Loss of cerebral autoregulation in the acute phase of ischemic stroke leaves patients vulnerable to blood pressure (BP) changes. Effective BP management after endovascular thrombectomy may protect the brain from hypoperfusion or hyperperfusion. In this observational study, we compared personalized, autoregulation-based BP targets to static systolic BP thresholds. Methods— We prospectively enrolled 90 patients undergoing endovascular thrombectomy for stroke. Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy–derived tissue oxygenation (a cerebral blood flow surrogate) in response to changes in mean arterial pressure. The resulting autoregulatory index was used to trend the BP range at which autoregulation was most preserved. Percent time that mean arterial pressure exceeded the upper limit of autoregulation or decreased below the lower limit of autoregulation was calculated for each patient. Time above fixed systolic BP thresholds was computed in a similar fashion. Functional outcome was measured with the modified Rankin Scale at 90 days. Results— Personalized limits of autoregulation were successfully computed in all 90 patients (age 71.6±16.2, 47% female, mean National Institutes of Health Stroke Scale 13.9±5.7, monitoring time 28.0±18.4 hours). Percent time with mean arterial pressure above the upper limit of autoregulation associated with worse 90-day outcomes (odds ratio per 10% 1.84 [95% CI, 1.3–2.7] P =0.002), and patients with hemorrhagic transformation spent more time above the upper limit of autoregulation (10.9% versus 16.0%, P =0.042). Although there appeared to be a nonsignificant trend towards worse outcome with increasing time above systolic BP thresholds of 140 mm Hg and 160 mm Hg, the effect sizes were smaller compared with the personalized approach. Conclusions— Noninvasive determination of personalized BP thresholds for stroke patients is feasible. Deviation from these limits may increase risk of further brain injury and poor functional outcome. This approach may present a better strategy compared with the classical approach of maintaining systolic BP below a predetermined value, though a randomized trial is needed to determine the optimal approach for hemodynamic management.

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Blood pressure levels post mechanical thrombectomy and outcomes in large vessel occlusion strokes

Goyal¹,

Tsivgoulis²,

Pandhi³

et al. 2017

Neurology

165

161

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E-014 Management of Blood Pressure for Acute Ischemic Stroke in the Modern Era of Mechanical Thrombectomy

Cited by 3 publications

References 0 publications

Are Postprocedural Blood Pressure Goals Associated With Clinical Outcome After Mechanical Thrombectomy for Acute Ischemic Stroke?

Are Postprocedural Blood Pressure Goals Associated With Clinical Outcome After Mechanical Thrombectomy for Acute Ischemic Stroke?

Fixed Compared With Autoregulation-Oriented Blood Pressure Thresholds After Mechanical Thrombectomy for Ischemic Stroke

Blood pressure levels post mechanical thrombectomy and outcomes in large vessel occlusion strokes

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