Blood Pressure in the First 6 Hours Following Endovascular Treatment for Ischemic Stroke Is Associated with Outcome

Noor Samuels*, Rob A. Van De Graaf, Carlijn A.L. Van Den Berg, Simone M. Uniken Venema, Kujtesa Bala, Pieter Jan Van Doormaal, Wouter Van Der Steen, Elbert Witvoet, Jelis Boiten, Heleen Den Hertog, Wouter J. Schonewille, Jeannette Hofmeijer, Floris Schreuder, Tobien A.H.C.M.L. Schreuder, H. Bart Van Der Worp, Yvo B.W.E.M. Roos, Charles B.L.M. Majoie, James F. Burke, Adriaan C.G.M. Van Es, Aad Van Der LugtBob Roozenbeek, Hester F. Lingsma, Diederik W.J. Dippel

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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Abstract

Background and Purpose: Optimal blood pressure (BP) management in the acute phase of ischemic stroke remains an unresolved issue. It is uncertain whether guidelines for BP management during and after intravenous alteplase can be extrapolated to endovascular treatment (EVT) for stroke due to large artery occlusion in the anterior circulation. We evaluated the associations between systolic BP (SBP) in the first 6 hours following EVT and functional outcome as well as symptomatic intracranial hemorrhage. Methods: Patients of 8 MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry centers, with available data on SBP in the 6 hours following EVT, were analyzed. We evaluated maximum, minimum, and mean SBP. Study outcomes were functional outcome (modified Rankin Scale) at 90 days and symptomatic intracranial hemorrhage. We used multivariable ordinal and binary regression analysis to adjust for important prognostic factors and studied possible effect modification by successful reperfusion. Results: Post-EVT SBP data were available for 1161/1796 patients. Higher maximum SBP (per 10 mm Hg increments) was associated with worse functional outcome (adjusted common odds ratio, 0.93 [95% CI, 0.88-0.98]) and a higher rate of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.17 [95% CI, 1.02-1.36]). The association between minimum SBP and functional outcome was nonlinear with an inflection point at 124 mm Hg. Minimum SBP lower and higher than the inflection point were associated with worse functional outcomes (adjusted common odds ratio, 0.85 per 10 mm Hg decrements [95% CI, 0.76-0.95] and adjusted common odds ratio, 0.81 per 10 mm Hg increments [95% CI, 0.71-0.92]). No association between mean SBP and functional outcome was observed. Successful reperfusion did not modify the relation of SBP with any of the outcomes. Conclusions: Maximum SBP in the first 6 hours following EVT is positively associated with worse functional outcome and an increased risk of symptomatic intracranial hemorrhage. Both lower and higher minimum SBP are associated with worse outcomes. A randomized trial to evaluate whether modifying post-intervention SBP results in better outcomes after EVT for ischemic stroke seems justified.

Original languageEnglish
Pages (from-to)3514-3522
Number of pages9
JournalStroke
Volume52
Issue number11
DOIs
Publication statusPublished - 1 Nov 2021

Bibliographical note

Sources of FundingThe MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treat-ment for Acute Ischemic Stroke in the Netherlands) Registry was partially funded by unrestricted grants from Toegepast Wetenschappelijk Instituut voor Neuro-modulatie, Twente University (TWIN), Erasmus MC University Medical Center, Maastricht University Medical Center, and Amsterdam UMC. The study was ad-ditionally funded by the European Union’s Horizon 2020 research and innovation program under grant agreement no. 777072 (INSIST [In-Silico Trials for Treat-ment of Acute Ischemic Stroke]). The funding sources had no role in study design, patient enrolment, data collection, analysis, writing of the article, approval of the article, and decision to submit the article for publication.

Publisher Copyright: © 2021 Lippincott Williams and Wilkins. All rights reserved.

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