High maximum BP after endovascular stroke therapy tied to hemorrhage risk, poor outcomes
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High maximum systolic BP in the immediate hours following endovascular therapy for ischemic stroke is associated with poor functional outcome and increased risk for symptomatic intracranial hemorrhage, according to data published in Stroke.
“Since BP is an important factor affecting cerebral perfusion, it is likely that BP within the first hours following EVT has an impact on infarct size and thereby functional outcome,” Noor Samuels, MD, of the department of radiology, neurology and public health at Erasmus MC University Medical Center in Rotterdam, the Netherlands. “If BP is causally related to outcome, modification using medication might be a feasible strategy to improve functional outcomes. We aimed to evaluate the associations of systolic BP in the first 6 hours following EVT with functional outcome and the occurrence of [symptomatic intracranial hemorrhage].”
Researchers utilized data from eight participating centers in the MR CLEAN trial.
This analysis included 1,161 patients who underwent endovascular therapy for stroke and had systolic BP measurements taken within 6 hours following endovascular therapy. Outcomes included modified Rankin Scale at 90 days and symptomatic intracranial hemorrhage.
Maximum and minimum BP after endovascular therapy
According to the study, patients with a higher maximum systolic BP (> 140 mm Hg) in the first 6 hours following endovascular therapy were older and more likely to have a history of atrial fibrillation, diabetes, hypertension, distal occlusion and poorer collateral scores.
Researchers observed that patients with greater maximum systolic BP in the early hours following endovascular therapy were at greater risk for worse functional outcomes compared with those with lower maximum systolic BP (adjusted OR per 10 mm Hg = 0.93; 95% CI, 0.88-0.98).
Higher maximum systolic BP was associated with poorer neurological outcomes at 24 to 48 hours after endovascular therapy (adjusted beta for NHYA scale score = 0.31; 95% CI, 0.14-0.49) and increased risk for symptomatic intracranial hemorrhage compared with lower maximum systolic BP (aOR per 10 mm Hg = 1.17; 95% CI, 1.02-1.36). However, risk for death was no greater among patients with higher maximum BP vs. lower maximum BP (aOR = 1.02; 95% CI, 0.95-1.08).
According to the study, the association between minimum systolic BP and functional outcome was not linear; therefor, researchers calculated the effect estimates for lower minimum and higher minimum systolic BP separately, with an inflection point at 124 mm Hg.
Researchers reported that minimum systolic BP below 124 mm Hg and minimum systolic BP above 124 mm Hg in the 6 hours following endovascular therapy were associated with poorer functional outcome (aOR per 10 mm Hg decrement for minimum systolic BP < 124 mm Hg = 0.85; 95% CI, 0.76-0.95; aOR per 10 mm Hg increment for minimum systolic BP 124 mm Hg = 0.81; 95% CI, 0.71-0.92).
Mean systolic BP after endovascular therapy
Similar to minimum systolic BP, the associations between mean systolic BP and functional outcome were also nonlinear; therefore, researchers calculated the effect estimates for lower mean and higher mean systolic BP separately, with an inflection point at 138 mm Hg.
According to the study, mean systolic BP lower than 138 mm Hg was associated with greater risk for extracranial hemorrhage (aOR per 10 mm Hg decrement = 1.66; 95% CI, 1.07-2.51). Researchers observed no association between mean systolic BP greater than 138 mm Hg and any of the outcomes.
Moreover, researchers found no association between extent of reperfusion and systolic BP and any of the outcomes.
“The explanation for the worse outcome observed in patients with higher maximum systolic BP is likely to be multifactorial, including disruption of the blood-brain barrier, hemorrhagic transformation, elevated serum catecholamine levels and larger infarcts,” the researchers wrote. “Given the clear association between BP and outcome after EVT, the lack of evidence on optimal BP management, the variation in hemodynamic management among EVT centers, and the possibility of a modifiable effect of BP on outcome, a clinical trial seems justified.”
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