Advertisement

Springer Nature is making Coronavirus research free. View research | View latest news | Sign up for updates

Prolonged Heightened Blood Pressure Following Mechanical Thrombectomy for Acute Stroke is Associated with Worse Outcomes

Abstract

Background

Most data evaluating the relationship of post-mechanical thrombectomy (MT) blood pressure (BP) management and outcomes of patients with large vessel occlusion (LVO) focus on early BP control within the first 24 h. We investigated the correlation of daily BP trends up to the third day following MT with patient outcomes.

Methods

We retrospectively reviewed our prospectively maintained database for LVO patients treated with MT from February 2015 to December 2017. Recorded BP values for 72 h post-reperfusion were reviewed. Daily peak systolic and diastolic blood pressures (SBP, DBP) were extracted for each day post-procedure. The association and importance between BP increments of 10 mmHg and mortality, hemorrhage, and functional independence (FI = mRS ≤ 2) was analyzed in a multivariable logistic regression and random forest (RF) analyses modeling.

Results

A total of 212 thrombectomies were included. An increase in peak 24-h SBP was independently associated with higher likelihood of symptomatic hemorrhage (OR 1.2, p = 0.048) and decreased functional independence (OR 0.85, p = 0.03). Higher day 2 and day 3 peak SBP was strongly correlated with decreased functional independence and higher mortality. Third day SBP < 140 was independently associated with higher likelihood of functional independence (OR 4.3, p = 0.0004). Post-MT patients with and without functional independence demonstrated a similar relative decrease in peak SBP between the first 2 days following thrombectomy (p = 0.26); however, those without functional independence experienced a significant rebound increase in peak SBP on the third day following MT (mean change from day 2 to 3: FI − 3.5 mmHg, non-FI + 3.9 mmHg; p = 0.005).

Conclusion

High daily maximum SBP and a rebound SBP on the third day following MT is independently associated with increased likelihood of functional dependence.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. 1.

    Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30.

  2. 2.

    Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285–95.

  3. 3.

    Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296–306.

  4. 4.

    Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–18.

  5. 5.

    Berkhemer OA, Fransen PSS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20.

  6. 6.

    Powers WJ, Derdeyn CP, Biller J, et al. American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(10):3020–35.

  7. 7.

    Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–31.

  8. 8.

    Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–99.

  9. 9.

    Maier B, Gory B, Taylor G, et al. Mortality and disability according to baseline blood pressure in acute ischemic stroke patients treated by thrombectomy: a collaborative pooled analysis. J Am Heart Assoc. 2017;6(10):e006484.

  10. 10.

    Goyal N, Tsivgoulis G, Pandhi A, et al. Blood pressure levels post mechanical thrombectomy and outcomes in non-recanalized large vessel occlusion patients. J Neurointerv Surg. 2018;10(10):925–31.

  11. 11.

    Goyal N, Tsivgoulis G, Pandhi A, et al. Blood pressure levels post mechanical thrombectomy and outcomes in large vessel occlusion strokes. Neurology. 2017;89(6):540–7.

  12. 12.

    Mistry EA, Mistry AM, Nakawah MO, et al. Systolic blood pressure within 24 hours after thrombectomy for acute ischemic stroke correlates with outcome. J Am Heart Assoc. 2017;6(5):e006167.

  13. 13.

    Mistry EA, Mayer SA, Khatri P. Blood pressure management after mechanical thrombectomy for acute ischemic stroke: a survey of the strokenet sites. J Stroke Cerebrovasc Dis. 2018;27(9):2474–8.

  14. 14.

    Sussman ES, Connolly ES Jr. Hemorrhagic transformation: a review of the rate of hemorrhage in the major clinical trials of acute ischemic stroke. Front Neurol. 2013;4:69.

  15. 15.

    Martins AI, Sargento-Freitas J, Silva F, et al. Recanalization modulates association between blood pressure and functional outcome in acute ischemic stroke. Stroke. 2016;47(6):1571–6.

  16. 16.

    Fluss R, Faraggi D, Reiser B. Estimation of the Youden Index and its associated cutoff point. Biom J. 2005;47(4):458–72.

  17. 17.

    Strobl C, Boulesteix A-L, Kneib T, Augustin T, Zeileis A. Conditional variable importance for random forests. BMC Bioinform. 2008;9:307.

  18. 18.

    Strobl C, Hothorn T, Zeileis A. Party on! R J. 2009;1(2):14–17. https://doi.org/10.32614/RJ-2009-013.

  19. 19.

    Maegerlein C, Mönch S, Boeckh-Behrens T, et al. PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy—evaluation of a double embolic protection approach in endovascular stroke treatment. J Neuro Interv Surg. 2017;10(8):751–5.

  20. 20.

    Turk AS, Frei D, Fiorella D, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014;6(4):260–4.

  21. 21.

    Warach S, Latour LL. Evidence of reperfusion injury, exacerbated by thrombolytic therapy, in human focal brain ischemia using a novel imaging marker of early blood-brain barrier disruption. Stroke. 2004;35(11 Suppl 1):2659–61.

  22. 22.

    Neumann-Haefelin T, Kastrup A, de Crespigny A, et al. Serial MRI after transient focal cerebral ischemia in rats: dynamics of tissue injury, blood-brain barrier damage, and edema formation. Stroke. 2000;31(8):1965–72 (discussion 72-3).

  23. 23.

    Rose JC, Mayer SA. Optimizing blood pressure in neurological emergencies. Neurocrit Care. 2004;1(3):287–99.

  24. 24.

    Bennett AE, Wilder MJ, McNally JS, et al. Increased blood pressure variability after endovascular thrombectomy for acute stroke is associated with worse clinical outcome. J Neurointerv Surg. 2018;10(9):823–7.

  25. 25.

    Martins AI, Sargento-Freitas J, Jesus-Ribeiro J, et al. Blood pressure variability in acute ischemic stroke: the role of early recanalization. Eur Neurol. 2018;80(1–2):63–7.

Download references

Funding

Study was unfunded.

Author information

DMC and RMS were involved in conception and design, acquisition, analysis, interpretation of data, drafting the article, final approval. MA and EL contributed to conception and design, revising article for important intellectual content, final approval. DS, JPB, OE, and JK were involved in conception and design, analysis, interpretation of data, revising article for important intellectual content, final approval.

Correspondence to David J. McCarthy.

Ethics declarations

Conflicts of interest

No authors have any relevant conflicts to disclose.

Ethical approval

All studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval for this study was granted by the local ethics committee.

Informed consent

Informed consent was obtained from all individual participants included in the study according to local regulations.

Data Sharing

The data will be made available upon request to the corresponding author.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

McCarthy, D.J., Ayodele, M., Luther, E. et al. Prolonged Heightened Blood Pressure Following Mechanical Thrombectomy for Acute Stroke is Associated with Worse Outcomes. Neurocrit Care 32, 198–205 (2020). https://doi.org/10.1007/s12028-019-00803-7

Download citation

Keywords

  • Stroke
  • Thrombectomy
  • Blood pressure
  • Outcomes