Pressor therapy in acute ischaemic stroke: an updated systematic review

Abstract

Background Low blood pressure (BP) in acute ischaemic stroke (AIS) is associated with poor functional outcome, death, or severe disability. Increasing BP might benefit patients with post-stroke hypotension including those with potentially salvageable ischaemic penumbra. This updated systematic review considers the present evidence regarding the use of vasopressors in AIS. Methods We searched the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and trial databases using a structured search strategy. We examined reference lists of relevant publications for additional studies examining BP elevation in AIS. Results We included 27 studies involving 1886 patients. Nine studies assessed increasing BP during acute reperfusion therapy (intravenous thrombolysis, mechanical thrombectomy, intra-arterial thrombolysis or combined). Eighteen studies tested BP elevation alone. Phenylephrine was the most commonly used agent to increase BP (n = 16 studies), followed by norepinephrine (n = 6), epinephrine (n = 3) and dopamine (n = 2). Because of small patient numbers and study heterogeneity, a meta-analysis was not possible. Overall, BP elevation was feasible in patients with fluctuating or worsening neurological symptoms, large vessel occlusion with labile BP, sustained post-stroke hypotension and ineligible for intravenous thrombolysis or after acute reperfusion therapy. The effects on functional outcomes were largely unknown and close monitoring is advised if such intervention is undertaken. Conclusion Although theoretical arguments support increasing BP to improve cerebral blood flow and sustain the ischaemic penumbra in selected AIS patients, the data are limited and results largely inconclusive. Large, randomised controlled trials are needed to identify the optimal BP target, agent, duration of treatment and effects on clinical outcomes.

Review of Cerebral Collateral Circulation and Insight into Cardiovascular Strategies to Limit Collateral Damage in Ischemic Stroke

“…Investigations into interventions to augment BP in the setting of acute ischemic stroke have not yielded clear BP targets, duration of therapy, or evidence of meaningful benefit. [36][37][38] Only a few studies thus far have demonstrated a potential role of induced hypertension in the treatment of acute stroke, particularly in patients who are not candidates for fibrinolytic or interventional therapies and with early neurologic deterioration. [39][40][41][42] For patients with fluctuating neurologic examinations or worsening deficits with drops in BP, volume expansion or pressure augmentation may be considered.…”

Noradrenaline‐induced changes in cerebral blood flow in health, traumatic brain injury and critical illness: a systematic review with meta‐analysis

“…Although a universally accepted definition of hypotension does not yet exist, brain perfusion is prioritised due to its high metabolic rate and lack of fuel storage, requiring a continuous supply of metabolic substrates and washing out of metabolic wastes via cerebral blood flow (CBF). Noradrenaline is one of the most commonly used vasopressors and is often a preferred choice for conditions including septic shock [1], traumatic brain injury [2], acute ischaemic stroke [3] and anaesthesia-related hypotension [4]. However, despite its widespread use, the effects of noradrenaline on CBF remain unresolved.…”