Nils H Petersen1, Sreeja Kodali1, Can Meng2, Fangyong Li3, Cindy Khanh Nguyen1, Krithika U Peshwe1, Sumita Strander1, Andrew Silverman1, Alexandra Kimmel1, Anson Wang1, Mohammad Anadani4, Eyad Almallouhi4, Alejandro M Spiotta5, Joon-Tae Kim6, James A Giles7, Salah G Keyrouz7, Mudassir Farooqui8, Cynthia Zevallos8, Ilko L Maier9, Marios-Nikos Psychogios10, Jan Liman9, Nolwenn Riou-Comte11, Sébastien Richard11,12, Benjamin Gory13,14, Stacey Quintero Wolfe15, Patrick A Brown16, Kyle M Fargen15, Eva A Mistry16, Hiba Fakhri16, Akshitkumar M Mistry17, Ka-Ho Wong18, Adam de Havenon18, Fábio A Nascimento19, Peter Kan19, Charles Matouk3, Santiago Ortega-Gutiérrez8, Kevin N Sheth1. 1. Department of Neurology (N.H.P., S.K., C.K.N., K.U.P., S.S., A.S., A.K., A.W., K.N.S.), Yale University School of Medicine, New Haven, CT. 2. Department of Neurosurgery (C.M), Yale University School of Medicine, New Haven, CT. 3. Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT (C.M., F.L.). 4. Department of Neurology (M.A., E.A.), Medical University of South Carolina, Charleston, SC. 5. Department of Neurosurgery (A.M.S.), Medical University of South Carolina, Charleston, SC. 6. Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea (J.-T.K.). 7. Department of Neurology, Washington University School of Medicine in St. Louis, MO (J.A.G., S.G.K.). 8. Department of Neurology, University of Iowa Carver College of Medicine, Iowa City (M.F., C.Z., S.O.-G.). 9. Department of Neurology, University Medical Center Göttingen, Germany (I.L.M., J.L.). 10. Department of Diagnostic and Interventional Neuroradiology, University Clinic Basel, Switzerland (M.-N.P.). 11. Department of Neurology (N.R.-C., S.R.), University Hospital of Nancy, France. 12. Centre d'Investigation Clinique Plurithématique, INSERM U1116, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France (S.R.). 13. Department of Neuroradiology (B.G.), University Hospital of Nancy, France. 14. IADI, INSERM U1254, University of Lorraine, Nancy, France (B.G.). 15. Department of Radiology (P.A.B), Wake Forest School of Medicine, Winston-Salem, NC. 16. Department of Neurology (E.A.M., H.F.), Vanderbilt University Medical Center, Nashville, TN. 17. Department of Neurosurgery (A.M.M.), Vanderbilt University Medical Center, Nashville, TN. 18. Department of Neurology, University of Utah School of Medicine, Salt Lake City (K.-H.W, A.d.H). 19. Department of Neurology, Baylor College of Medicine, Houston, TX (F.A.N, P.K.).
Abstract
BACKGROUND: Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes. METHODS: This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the modified Rankin Scale 90 days after stroke. Secondary outcomes included hemorrhagic transformation, symptomatic intracranial hemorrhage, and death. RESULTS: Two thousand two hundred sixty-eight patients (mean age [±SD] 69±15, mean National Institutes of Health Stroke Scale 15±7) were included in the analysis. Five distinct SBP trajectories were observed: low (18%), moderate (37%), moderate-to-high (20%), high-to-moderate (18%), and high (6%). SBP trajectory group was independently associated with functional outcome at 90 days (P<0.0001) after adjusting for potential confounders. Patients with high and high-to-moderate SBP trajectories had significantly greater odds of an unfavorable outcome (adjusted odds ratio, 3.5 [95% CI, 1.8-6.7], P=0.0003 and adjusted odds ratio, 2.2 [95% CI, 1.5-3.2], P<0.0001, respectively). Subjects in the high-to-moderate group had an increased risk of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.82 [95% CI, 1-3.2]; P=0.04). No significant association was found between trajectory group and hemorrhagic transformation. CONCLUSIONS: Patients with acute ischemic stroke demonstrate distinct SBP trajectories during the first 72 hours after EVT that have differing associations with functional outcome. These findings may help identify potential candidates for future blood pressure modulation trials.
BACKGROUND: Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes. METHODS: This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the modified Rankin Scale 90 days after stroke. Secondary outcomes included hemorrhagic transformation, symptomatic intracranial hemorrhage, and death. RESULTS: Two thousand two hundred sixty-eight patients (mean age [±SD] 69±15, mean National Institutes of Health Stroke Scale 15±7) were included in the analysis. Five distinct SBP trajectories were observed: low (18%), moderate (37%), moderate-to-high (20%), high-to-moderate (18%), and high (6%). SBP trajectory group was independently associated with functional outcome at 90 days (P<0.0001) after adjusting for potential confounders. Patients with high and high-to-moderate SBP trajectories had significantly greater odds of an unfavorable outcome (adjusted odds ratio, 3.5 [95% CI, 1.8-6.7], P=0.0003 and adjusted odds ratio, 2.2 [95% CI, 1.5-3.2], P<0.0001, respectively). Subjects in the high-to-moderate group had an increased risk of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.82 [95% CI, 1-3.2]; P=0.04). No significant association was found between trajectory group and hemorrhagic transformation. CONCLUSIONS: Patients with acute ischemic stroke demonstrate distinct SBP trajectories during the first 72 hours after EVT that have differing associations with functional outcome. These findings may help identify potential candidates for future blood pressure modulation trials.
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