Association between blood pressure variability and clinical outcomes after successful recanalization in patients with large vessel occlusion stroke after mechanical thrombectomy

 The whole problem here is that there is NO blood pressure management protocol post stroke. This did nothing to solve that problem.

Association between blood pressure variability and clinical outcomes after successful recanalization in patients with large vessel occlusion stroke after mechanical thrombectomy

You Lu^1†, Rui Shen^2†, Wenjian Lin¹, Xiaoyu Zhou¹, Jian Hu^3* and Quanbin Zhang^2*

• ¹Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
• ²Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
• ³Department of Radiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China

Objective: Nearly half of patients who undergo mechanical thrombectomy (MT) do not experience a favorable outcome. The association between blood pressure fluctuation and clinical outcomes after successful MT is controversial. We evaluated the influence of blood pressure variability (BPV) on the clinical outcomes of stroke patients with large vessel occlusion (LVO) who underwent successful recanalization after MT.

Methods: Patients with anterior circulation LVO stroke who underwent successful emergency MT (modified Thrombolysis in Cerebral Infarction, mTICI ≥ 2b) at the Shanghai Tenth People's Hospital of Tongji University from 2017 to 2021 were enrolled. Multivariate logistic models were used to investigate the association between BPV (mean arterial pressure [MAP] assessed using the standard deviation [SD]) and clinical outcomes. The primary outcome was 90-day modified Rankin Scale scores (mRS), and the secondary outcomes were 30-day mortality and symptomatic intracranial hemorrhage (sICH).

Results: A total of 458 patients (56.8% men), with a mean age of 72 ± 1 years, were enrolled. Among them, 207 (45.2%) patients had unfavorable functional outcomes (mRS score 3–6) at 90 days, 61 (13.3%) patients died within 30 days, and 20 (4.4%) patients had sICH. In a fully adjusted model, BPV was associated with a higher risk of a 90-day mRS score of 3–6 (P = 0.04), 30-day mortality (P < 0.01), and sICH (P < 0.01). A significant interaction between MAP SD and rescue futile recanalization treatment was observed (P < 0.01).

Conclusions: Among patients with LVO stroke who underwent successful recanalization, higher BPV was associated with worse functional outcomes, especially in those who underwent rescue treatment.

Introduction

Large vessel occlusion (LVO) stroke is associated with a 4.5-fold increased risk of mortality compared to non-LVO stroke (1). Mechanical thrombectomy (MT) is the most effective treatment method for patients with LVO stroke and has a one-fold higher recanalization rate when compared to intravenous thrombolysis for patients with acute ischemic stroke caused by anterior circulation LVO. However, nearly half of patients with successful recanalization fail to achieve functional improvement (2).

Hypertension is one of the most common risk factors for stroke (3). Most observational studies have suggested that increased blood pressure (BP) after MT increases mortality and symptomatic intracranial hemorrhage (sICH) (4, 5). However, BP management after endovascular therapy remains a clinical challenge. The American Stroke Association (ASA) guidelines recommend maintaining a BP level of <180/105 mmHg for 24 h after MT, based on low-level evidence (6). In the DAWN trial, a systolic blood pressure (SBP) of <140 mmHg is maintained in the first 24 h in patients with successful reperfusion (defined as achieving a modified Thrombolysis in Cerebral Infarction (mTICI) grading system score of 2b-3) after MT (7). Contrarily, 62% of the stroke centers in the USA set a target SBP of <160 mmHg for patients with successful reperfusion (8). There were no significant differences in the efficacies between the intensive and non-intensive arms in the BP-TARGET trial, suggesting BP parameters other than SBP may be closely associated with clinical outcomes (9).

Blood pressure variability (BPV) has been reported to be a better predictor of all-cause and cardiovascular mortality and cardiac disease than other BP paraments (10). The influence of BPV on clinical outcomes in stroke patients has recently attracted growing attention (11, 12). However, conflicting conclusions have been reported regarding the association between BPV and clinical outcomes after MT. A secondary analysis of the prospective cohort study BEST revealed that higher BPV is associated with exacerbated 90-day outcomes (13), and yet post hoc analyses of the random clinical trial BP-TARGET suggested that BPV was not associated with functional outcomes (14).

Therefore, we performed a retrospective cohort study to investigate the association between BPV after successful recanalization and clinical outcomes in patients with LVO after MT.

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