TY - JOUR
T1 - Blood pressure in the first 6 hours following endovascular treatment for ischemic stroke is associated with outcome
AU - Samuels, Noor
AU - van de Graaf, Rob A.
AU - van den Berg, Carlijn A.L.
AU - Uniken Venema, Simone M.
AU - Bala, Kujtesa
AU - van Doormaal, Pieter Jan
AU - van der Steen, Wouter
AU - Witvoet, Elbert
AU - Boiten, Jelis
AU - den Hertog, Heleen
AU - Schonewille, Wouter J.
AU - Hofmeijer, Jeannette
AU - Schreuder, Floris
AU - Schreuder, Tobien A.H.C.M.L.
AU - van der Worp, H. Bart
AU - Roos, Yvo B.W.E.M.
AU - Majoie, Charles B.L.M.
AU - Burke, James F.
AU - van Es, Adriaan C.G.M.
AU - van der Lugt, Aad
AU - Roozenbeek, Bob
AU - Lingsma, Hester F.
AU - Dippel, Diederik W.J.
N1 - Funding Information:
The MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry was partially funded by unrestricted grants from Toegepast Wetenschappelijk Instituut voor Neuromodulatie, Twente University (TWIN), Erasmus MC University Medical Center, Maastricht University Medical Center, and Amsterdam UMC. The study was additionally funded by the European Union’s Horizon 2020 research and innovation program under grant agreement no. 777072 (INSIST [In-Silico Trials for Treatment 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.
Funding Information:
Dr Dippel reports funding from the Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Sciences and Health, and unrestricted grants from Penumbra Inc, Stryker European Operations BV, Medtronic, Thrombolytic Science, LLC and Cerenovus for research, all paid to the institution. Dr van der Lugt reports funding from Dutch Heart Foundation, Dutch Brain Foundation, Stryker, Angiocare BV, Medtronic/Covidien/EV3, MEDAC Gmbh/LAMEPRO, Penumbra, Cerenovus, Thrombolytic Science LLC, and Top Medical Concentric, all paid to institution. Dr van Doormaal reports funding from Stryker, paid to institution. Dr Burke reports grants from the National Institutes of Health (NIH). Dr Majoie reports funding from CVON/Dutch Heart Foundation, Stryker, Health Evaluation Netherlands all paid to institution and is shareholder of Nico.lab, a company that focuses on the use of artificial intelligence for medical imaging analysis. Dr Roos reports funding from CVON/Dutch Heart Foundation, Stryker, Health Evaluation Netherlands all paid to institution and reports being shareholder of Nico.lab, a company that focuses on the use of artificial intelligence for medical imaging analysis. Dr Schreuder reports grants from the Dutch Heart Foundation. Dr van der Worp reports funding from Bayer, Boehringer Ingelheim, and LivaNova for consultation, grants from Stryker and Dutch Heart Foundation, all paid to institution. The other authors report no conflicts.
Publisher Copyright:
© 2021 The Authors.
PY - 2021/11
Y1 - 2021/11
N2 - 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 mmHg 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 mmHg. Minimum SBP lower and higher than the inflection point were associated with worse functional outcomes (adjusted common odds ratio, 0.85 per 10 mmHg decrements [95% CI, 0.76–0.95] and adjusted common odds ratio, 0.81 per 10 mmHg 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.
AB - 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 mmHg 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 mmHg. Minimum SBP lower and higher than the inflection point were associated with worse functional outcomes (adjusted common odds ratio, 0.85 per 10 mmHg decrements [95% CI, 0.76–0.95] and adjusted common odds ratio, 0.81 per 10 mmHg 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.
KW - Blood pressure
KW - Cerebral hemorrhage
KW - Guideline
KW - Ischemic stroke
KW - Reperfusion
UR - http://www.scopus.com/inward/record.url?scp=85119019290&partnerID=8YFLogxK
U2 - 10.1161/STROKEAHA.120.033657
DO - 10.1161/STROKEAHA.120.033657
M3 - Article
C2 - 34538090
AN - SCOPUS:85119019290
SN - 0039-2499
VL - 52
SP - 3514
EP - 3522
JO - Stroke
JF - Stroke
IS - 11
ER -
