Association of Blood Pressure at Successful Recanalization and Parenchymal Hemorrhage After Mechanical Thrombectomy With General Anesthesia

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Association of Blood Pressure at Successful Recanalization and Parenchymal Hemorrhage After Mechanical Thrombectomy With General Anesthesia

Hui Cheng^1†, Chao Xu^2†, Xing Jin¹, Yigang Chen¹, Xu Zheng¹, Feina Shi¹, Xudong He¹, Yonggang Hao¹, Yun Jiang¹, Jinhua Zhang^1* and Zhicai Chen^3*

• ¹Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
• ²Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
• ³Department of Neurology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China

Background: This study aims to investigate the association between blood pressure (BP) at the time of recanalization and hemorrhagic transformation in large vessel occlusion (LVO) patients following mechanical thrombectomy (MT) with general anesthesia.

Methods: We retrospectively reviewed our data base for patients with acute ischemic stroke acute ischemic stroke (AIS) who received MT between January 2018 and December 2019. The BP at two adjacent time points immediately after successful recanalization was recorded for subsequent calculation of mean BP (BP_mean), maximum BP (BP_max), minimum BP (BP_min), range of BP (BP_range), and standard deviation of SP (BP_SD). Hemorrhagic transformation was identified on 24-h computerized tomography images according to the European Cooperative Acute Stroke Study (ECASS) III trial. We used binary logistic regression analysis to investigate the association of BP parameters and the incidence of parenchymal hemorrhage (PH) and PH-2.

Results: A total of 124 patients with anterior circulation LVO were finally included for analyses. After controlling for intravenous thrombolysis, procedure duration of mechanical thrombectomy, baseline National institutes of Health Stroke Scale (NIHSS), baseline ASPECTS, and number of device passes, the results showed that every increment of 10 mmHg in SBP_range (OR 1.559; 95% CI 1.027–2.365; P = 0.037) and SBP_SD (OR 1.998; 95% CI 1.017–3.925; P = 0.045) were independently associated with PH. After adjustment for intravenous thrombolysis, procedure duration of mechanical thrombectomy, baseline NIHSS, the results showed that every increment of 10 mmHg in SBP_mean (OR 1.973; 95% CI 1.190–3.271; P = 0.008), SBP_max (OR 1.838; 95% CI 1.199 to 2.815; P = 0.005), SBP_range (OR 1.908; 95% CI 1.161–3.136; P = 0.011) and SBP_SD (OR 2.573; 95% CI 1.170–5.675; P = 0.019) were independently associated with PH-2.

Conclusion: Patients with higher systolic BP and variability at the time of successful recanalization were more likely to have PH-2 in LVO patients following MT with general anesthesia.

Introduction

Mechanical thrombectomy (MT) for large vessel occlusion (LVO) has proved to be the new standard of therapy in acute ischemic stroke (AIS) (1). But more than 50% of patients still have unfavorable outcomes after early successful recanalization (2). The most severe complication is hemorrhagic transformation (HT), especially parenchymal hemorrhage (PH), which could result in early neurological deterioration and long-term outcomes (3). The current guidelines from the American Heart Association/American Stroke Association guidelines arbitrarily recommend blood pressure (BP) control of <180/105 mm Hg during and after MT. However, data regarding guidance for optimal BP management among patients treated with MT remain scarce (4). Theoretically, the target of BP control should be lower in patients following MT because of the high hemorrhagic transformation risk after clot removal (5).

Several studies have shown that blood pressure after MT is related to 

Introduction

Mechanical thrombectomy (MT) for large vessel occlusion (LVO) has proved to be the new standard of therapy in acute ischemic stroke (AIS) (1). But more than 50% of patients still have unfavorable outcomes after early successful recanalization (2). The most severe complication is hemorrhagic transformation (HT), especially parenchymal hemorrhage (PH), which could result in early neurological deterioration and long-term outcomes (3). The current guidelines from the American Heart Association/American Stroke Association guidelines arbitrarily recommend blood pressure (BP) control of <180/105 mm Hg during and after MT. However, data regarding guidance for optimal BP management among patients treated with MT remain scarce (4). Theoretically, the target of BP control should be lower in patients following MT because of the high hemorrhagic transformation risk after clot removal (5).

Several studies have shown that blood pressure after MT is related to hemorrhagic transformation. Goyal et al. have found that elevated maximum systolic BP levels during the first 24 h following MT are independently correlated with worse functional outcomes in LVO patients (6). Another previous study involving 182 patients found that increased BP variability during the first 24 h predicts worse neurologic outcomes in AIS patients treated with intra-arterial therapies (7). In most of the previous studies on the relationship between BP and hemorrhagic transformation, blood pressure was taken after admission to the neurologic intensive care unit. There are few studies on BP at the time of recanalization and hemorrhagic transformation in LVO patients following MT with general anesthesia.

In light of these considerations, we aimed to investigate the relationship between BP at the time of recanalization and hemorrhagic transformation and hypothesized that patients with elevated BP had higher risk of hemorrhagic transformation.

. Goyal et al. have found that elevated maximum systolic BP levels during the first 24 h following MT are independently correlated with worse functional outcomes in LVO patients (6). Another previous study involving 182 patients found that increased BP variability during the first 24 h predicts worse neurologic outcomes in AIS patients treated with intra-arterial therapies (7). In most of the previous studies on the relationship between BP and hemorrhagic transformation, blood pressure was taken after admission to the neurologic intensive care unit. There are few studies on BP at the time of recanalization and hemorrhagic transformation in LVO patients following MT with general anesthesia.

In light of these considerations, we aimed to investigate the relationship between BP at the time of recanalization and hemorrhagic transformation and hypothesized that patients with elevated BP had higher risk of hemorrhagic transformation.

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