Management of Blood Pressure During and After Recanalization Therapy for Acute Ischemic Stroke

So we still have NO FUCKING CLUE what a blood pressure management protocol is. Hope you don't mind dying because of the cesspools of incompetence of the complete stroke medical world.  Unless YOU hold your stroke hospital's feet to the fire you are allowing your children and grandchildren to die or become disabled.

 

Management of Blood Pressure During and After Recanalization Therapy for Acute Ischemic Stroke

Jeffrey R. Vitt¹, Michael Trillanes² and J. Claude Hemphill III^1*

• ¹Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
• ²Department of Pharmaceutical Services, University of California, San Francisco, San Francisco, CA, United States

Ischemic stroke is a common neurologic condition and can lead to significant long term disability and death. Observational studies have demonstrated worse outcomes in patients presenting with the extremes of blood pressure as well as with hemodynamic variability. Despite these associations, optimal hemodynamic management in the immediate period of ischemic stroke remains an unresolved issue, particularly in the modern era of revascularization therapies. While guidelines exist for BP thresholds during and after thrombolytic therapy, there is substantially less data to guide management during mechanical thrombectomy. Ideal blood pressure targets after attempted recanalization depend both on the degree of reperfusion achieved as well as the extent of infarction present. Following complete reperfusion, lower blood pressure targets may be warranted to prevent reperfusion injury and promote penumbra recovery however prospective clinical trials addressing this issue are warranted.

Introduction

Stroke is a common neurologic emergency worldwide with an overall growing incidence particularly in low to middle income countries where there has been over a 100% increase in stroke events over the past four decades (1). Approximately 85% are ischemic in origin and for the past two decades, intravenous tissue plasminogen activator (IV t-PA) has been the mainstay of treatment for patients with acute ischemic stroke (AIS) presenting within 3, and then expanded to 4.5, hours since last known well (2, 3). IV t-PA reduces the rate of functional dependence in up to one-third of individuals, but many AIS patients do not benefit from this treatment (2, 3). Over the past several years, multiple landmark studies have provided overwhelming evidence that intraarterial therapy (IAT) with mechanical thrombectomy, performed within 6 h of last known well in large vessel occlusion (LVO), leads to significantly improved functional outcomes and reduced mortality (4–7). More recently, the DEFUSE III and DAWN trials demonstrated that IAT can benefit patients treated out to 16 and 24 h if they have a favorable mismatch pattern on perfusion imaging (8, 9). While these breakthroughs have altered the paradigm of acute stroke management and can be considered as part of routine care, several unresolved issues remain regarding the optimal treatment of patients presenting with AIS, particularly regarding hemodynamic management. Though blood pressure (BP) elevation is common in AIS, the prognostic significance of this is unclear (10, 11). Some studies have found a correlation between hypertension and poor outcomes while others have reported inverse relationships (12–15). Furthermore, the guidelines for hemodynamic treatment following thrombolytic therapy in AIS are largely extrapolated from the IV t-PA trials as well as retrospective analyses (16). Thus, high quality evidence to guide management after IAT is lacking. The purpose of this review is to discuss the physiology and available data regarding hemodynamics in AIS with particular focus on how blood pressure might be optimally managed throughout the revascularization process.

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