Blood Pressure Management Before, During, and After Endovascular Thrombectomy for Acute Ischemic Stroke

Abstract

There is an absence of specific evidence or guideline recommendations on blood pressure management for large vessel occlusion stroke patients. Until randomized data are available, the periprocedural blood pressure management of patients undergoing endovascular thrombectomy can be viewed in two phases relative to the achievement of recanalization. In the hyperacute phase, prior to recanalization, hypotension should be avoided to maintain adequate penumbral perfusion. The American Heart Association guidelines should be followed for the upper end of prethrombectomy blood pressure: ≤185/110 mm Hg, unless post–tissue plasminogen activator administration when the goal is <180/105 mm Hg. After successful recanalization (thrombolysis in cerebral infarction [TICI]: 2b–3), we recommend a target of a maximum systolic blood pressure of < 160 mm Hg, while the persistently occluded patients (TICI < 2b) may require more permissive goals up to <180/105 mm Hg. Future research should focus on generating randomized data on optimal blood pressure management both before and after endovascular thrombectomy, to optimize patient outcomes for these divergent clinical scenarios.

Keywords

blood pressure - acute ischemic stroke - large vessel occlusion

Publikationsverlauf

Artikel online veröffentlicht:
20. Januar 2021

• References

• 1 Vemmos KN, Tsivgoulis G, Spengos K. et al. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J Intern Med 2004; 255 (02) 257-265
• 2 Petersen NH, Ortega-Gutierrez S, Wang A. et al. Decreases in blood pressure during thrombectomy are associated with larger infarct volumes and worse functional outcome. Stroke 2019; 50 (07) 1797-1804
• 3 Vitt JR, Trillanes M, Hemphill III JC. Management of blood pressure during and after recanalization therapy for acute ischemic stroke. Front Neurol 2019; 10: 138
• 4 Potter JF, Robinson TG, Ford GA. et al. Controlling hypertension and hypotension immediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol 2009; 8 (01) 48-56
• 5 Hubert GJ, Muller-Barna P, Haberl RL. Unsolved Issues in the Management of High Blood Pressure in Acute Ischemic Stroke. Int J Hypertens [online serial]. 2013. Accessed October 23, 2013 at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3655558/
• 6 Willmot M, Leonardi-Bee J, Bath PMW. High blood pressure in acute stroke and subsequent outcome: a systematic review. Hypertension 2004; 43 (01) 18-24
• 7 Powers WJ, Rabinstein AA, Ackerson T. et al; American Heart Association Stroke Council. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018; 49 (03) e46-e110
• 8 Powers WJ, Rabinstein AA, Ackerson T. et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019; 50 (12) e344-e418
• 9 Mistry EA, Mayer SA, Khatri P. Blood pressure management after mechanical thrombectomy for acute ischemic stroke: a survey of the StrokeNet sites. J Stroke Cerebrovasc Dis 2018; 27 (09) 2474-2478
• 10 Eva M, Katarina D, Nils P. et al. Abstract 110: pre-endovascular therapy change in BP is associated with outcome: a post-hoc analysis of the Blood Pressure After Endovascular Treatment (BEST) prospective cohort study. Stroke 2019; 50: A110
• 11 Wahlgren N, Ahmed N, Eriksson N. et al; Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy Investigators. Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled trials: Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy (SITS-MOST). Stroke 2008; 39 (12) 3316-3322
• 12 Ahmed N, Wahlgren N, Brainin M. et al; SITS Investigators. Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Stroke 2009; 40 (07) 2442-2449
• 13 Tsivgoulis G, Frey JL, Flaster M. et al. Pre-tissue plasminogen activator blood pressure levels and risk of symptomatic intracerebral hemorrhage. Stroke 2009; 40 (11) 3631-3634
• 14 Bath PM, Scutt P, Anderson CS. et al; RIGHT-2 Investigators. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomised, sham-controlled, blinded, phase 3 trial. Lancet 2019; 393 (10175): 1009-1020
• 15 Schrader J, Lüders S, Kulschewski A. et al; Acute Candesartan Cilexetil Therapy in Stroke Survivors Study Group. The ACCESS Study: evaluation of acute candesartan cilexetil therapy in stroke survivors. Stroke 2003; 34 (07) 1699-1703
• 16 Barer DH, Cruickshank JM, Ebrahim SB, Mitchell JR. Low dose beta blockade in acute stroke (“BEST” trial): an evaluation. Br Med J (Clin Res Ed) 1988; 296 (6624): 737-741
• 17 Sandset EC, Bath PM, Boysen G. et al; SCAST Study Group. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet 2011; 377 (9767): 741-750
• 18 Bath PMW, Krishnan K. Interventions for deliberately altering blood pressure in acute stroke. Cochrane Database Syst Rev 2014; (10) CD000039
• 19 Anderson CS, Huang Y, Lindley RI. et al; ENCHANTED Investigators and Coordinators. Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial. Lancet 2019; 393 (10174): 877-888
• 20 Britton M, Carlsson A, de Faire U. Blood pressure course in patients with acute stroke and matched controls. Stroke 1986; 17 (05) 861-864
• 21 Morfis L, Schwartz RS, Poulos R, Howes LG. Blood pressure changes in acute cerebral infarction and hemorrhage. Stroke 1997; 28 (07) 1401-1405
• 22 Anderson CS, Arima H, Lavados P. et al; HeadPoST Investigators and Coordinators. Cluster-randomized, crossover trial of head positioning in acute stroke. N Engl J Med 2017; 376 (25) 2437-2447
• 23 Ali LK, Weng JK, Starkman S. et al. Heads up! A novel provocative maneuver to guide acute ischemic stroke management. Intervent Neurol 2017; 6 (1-2): 8-15
• 24 Regenhardt RW, Das AS, Stapleton CJ. et al. Blood pressure and penumbral sustenance in stroke from large vessel occlusion. Front Neurol 2017; 8: 317
• 25 Drummond JC, Oh YS, Cole DJ, Shapiro HM. Phenylephrine-induced hypertension reduces ischemia following middle cerebral artery occlusion in rats. Stroke 1989; 20 (11) 1538-1544
• 26 Astrup J, Symon L, Branston NM, Lassen NA. Cortical evoked potential and extracellular K+ and H+ at critical levels of brain ischemia. Stroke 1977; 8 (01) 51-57
• 27 Hayashi S, Nehls DG, Kieck CF, Vielma J, DeGirolami U, Crowell RM. Beneficial effects of induced hypertension on experimental stroke in awake monkeys. J Neurosurg 1984; 60 (01) 151-157
• 28 Rordorf G, Koroshetz WJ, Ezzeddine MA, Segal AZ, Buonanno FS. A pilot study of drug-induced hypertension for treatment of acute stroke. Neurology 2001; 56 (09) 1210-1213
• 29 Hillis AE, Wityk RJ, Beauchamp NJ, Ulatowski JA, Jacobs MA, Barker PB. Perfusion-weighted MRI as a marker of response to treatment in acute and subacute stroke. Neuroradiology 2004; 46 (01) 31-39
• 30 Wityk RJ. Blood pressure augmentation in acute ischemic stroke. J Neurol Sci 2007; 261 (1-2): 63-73
• 31 Marzan AS, Hungerbühler H-J, Studer A, Baumgartner RW, Georgiadis D. Feasibility and safety of norepinephrine-induced arterial hypertension in acute ischemic stroke. Neurology 2004; 62 (07) 1193-1195
• 32 Koenig MA, Geocadin RG, de Grouchy M. et al. Safety of induced hypertension therapy in patients with acute ischemic stroke. Neurocrit Care 2006; 4 (01) 3-7
• 33 de Havenon A, Sultan-Qurraie A, Hannon P, Tirschwell D. Development of regional stroke programs. Curr Neurol Neurosci Rep 2015; 15 (05) 544
• 34 Talke PO, Sharma D, Heyer EJ, Bergese SD, Blackham KA, Stevens RD. Society for Neuroscience in Anesthesiology and Critical Care Expert consensus statement: anesthetic management of endovascular treatment for acute ischemic stroke*: endorsed by the Society of NeuroInterventional Surgery and the Neurocritical Care Society. J Neurosurg Anesthesiol 2014; 26 (02) 95-108
• 35 Jumaa MA, Zhang F, Ruiz-Ares G. et al. Comparison of safety and clinical and radiographic outcomes in endovascular acute stroke therapy for proximal middle cerebral artery occlusion with intubation and general anesthesia versus the nonintubated state. Stroke 2010; 41 (06) 1180-1184
• 36 Abou-Chebl A, Lin R, Hussain MS. et al. Conscious sedation versus general anesthesia during endovascular therapy for acute anterior circulation stroke: preliminary results from a retrospective, multicenter study. Stroke 2010; 41 (06) 1175-1179
• 37 Abou-Chebl A, Zaidat OO, Castonguay AC. et al. North American SOLITAIRE Stent-Retriever Acute Stroke Registry: choice of anesthesia and outcomes. Stroke 2014; 45 (05) 1396-1401
• 38 Brinjikji W, Pasternak J, Murad MH. et al. Anesthesia-related outcomes for endovascular stroke revascularization: a systematic review and meta-analysis. Stroke 2017; 48 (10) 2784-2791
• 39 Treurniet KM, Berkhemer OA, Immink RV. et al; MR CLEAN Investigators. A decrease in blood pressure is associated with unfavorable outcome in patients undergoing thrombectomy under general anesthesia. J Neurointerv Surg 2018; 10 (02) 107-111
• 40 Simonsen CZ, Yoo AJ, Sørensen LH. et al. Effect of general anesthesia and conscious sedation during endovascular therapy on infarct growth and clinical outcomes in acute ischemic stroke: a randomized clinical trial. JAMA Neurol 2018; 75 (04) 470-477
• 41 Schönenberger S, Uhlmann L, Hacke W. et al. Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy: a randomized clinical trial. JAMA 2016; 316 (19) 1986-1996
• 42 Schönenberger S, Uhlmann L, Ungerer M. et al. Association of blood pressure with short- and long-term functional outcome after stroke thrombectomy: post hoc analysis of the SIESTA trial. Stroke 2018; 49 (06) 1451-1456
• 43 Löwhagen Hendén P, Rentzos A, Karlsson J-E. et al. Hypotension during endovascular treatment of ischemic stroke is a risk factor for poor neurological outcome. Stroke 2015; 46 (09) 2678-2680
• 44 Whalin MK, Halenda KM, Haussen DC. et al. Even small decreases in blood pressure during conscious sedation affect clinical outcome after stroke thrombectomy: an analysis of hemodynamic thresholds. AJNR Am J Neuroradiol 2017; 38 (02) 294-298
• 45 Mistry EA, Mistry AM, Nakawah MO. et al. Systolic blood pressure within 24 hours after thrombectomy for acute ischemic stroke correlates with outcome. J Am Heart Assoc 2017; 6 (05) 6
• 46 Goyal N, Tsivgoulis G, Pandhi A. et al. Blood pressure levels post mechanical thrombectomy and outcomes in large vessel occlusion strokes. Neurology 2017; 89 (06) 540-547
• 47 Anadani M, Orabi Y, Alawieh A. et al. Blood pressure and outcome post mechanical thrombectomy. J Clin Neurosci 2019; 62: 94-99
• 48 Jadhav AP, Molyneaux BJ, Hill MD, Jovin TG. Care of the post-thrombectomy patient. Stroke 2018; 49 (11) 2801-2807
• 49 Manning LS, Rothwell PM, Potter JF, Robinson TG. Prognostic significance of short-term blood pressure variability in acute stroke: systematic review. Stroke 2015; 46 (09) 2482-2490
• 50 de Havenon A, Bennett A, Stoddard GJ. et al. Determinants of the impact of blood pressure variability on neurological outcome after acute ischaemic stroke. Stroke Vasc Neurol 2017; 2 (01) 1-6
• 51 Jordan JD, Powers WJ. Cerebral autoregulation and acute ischemic stroke. Am J Hypertens 2012; 25 (09) 946-950
• 52 Bennett AE, Wilder MJ, McNally JS. et al. Increased blood pressure variability after endovascular thrombectomy for acute stroke is associated with worse clinical outcome. J Neurointerv Surg 2018; 10 (09) 823-827
• 53 Chang JY, Jeon SB, Lee JH, Kwon O-K, Han M-K. The relationship between blood pressure variability, recanalization degree, and clinical outcome in large vessel occlusive stroke after an intra-arterial thrombectomy. Cerebrovasc Dis 2018; 46 (5-6): 279-286
• 54 Maier IL, Tsogkas I, Behme D. et al. High systolic blood pressure after successful endovascular treatment affects early functional outcome in acute ischemic stroke. Cerebrovasc Dis 2018; 45 (1-2): 18-25
• 55 Bösel J. Intensive care management of the endovascular stroke patient. Semin Neurol 2016; 36 (06) 520-530
• 56 Al-Mufti F, Dancour E, Amuluru K. et al. Neurocritical care of emergent large-vessel occlusion: the era of a new standard of care. J Intensive Care Med 2017; 32 (06) 373-386
• 57 Sheth KN, Sims JR. Neurocritical care and periprocedural blood pressure management in acute stroke. Neurology 2012; 79 (13, Suppl 1): S199-S204
• 58 Cernik D, Sanak D, Divisova P. et al. Impact of blood pressure levels within first 24 hours after mechanical thrombectomy on clinical outcome in acute ischemic stroke patients. J Neurointerv Surg 2019; 11 (08) 735-739
• 59 Mistry EA, Heidi S, Mistry AM. et al. Abstract 94: Blood Pressure After Endovascular Stroke Therapy (BEST): final results of a prospective multicenter cohort validation study. Stroke 2019; 50: A94
• 60 Jovin TG, Saver JL, Ribo M. et al. Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods. Int J Stroke 2017; 12 (06) 641-652
• 61 Wohlfahrt P, Krajcoviechova A, Jozifova M. et al. Low blood pressure during the acute period of ischemic stroke is associated with decreased survival. J Hypertens 2015; 33 (02) 339-345
• 62 Lehman LW, Saeed M, Moody G, Mark R. Hypotension as a risk factor for acute kidney injury in ICU patients. Comput Cardiol (2010) 2010; 37 (37) 1095-1098
• 63 Martins AI, Sargento-Freitas J, Silva F. et al. Recanalization modulates association between blood pressure and functional outcome in acute ischemic stroke. Stroke 2016; 47 (06) 1571-1576
• 64 Berge E, Cohen G, Lindley RI. et al. Effects of blood pressure and blood pressure-lowering treatment during the first 24 hours among patients in the Third International Stroke Trial of Thrombolytic Treatment for Acute Ischemic Stroke. Stroke 2015; 46 (12) 3362-3369
• 65 Delgado-Mederos R, Ribo M, Rovira A. et al. Prognostic significance of blood pressure variability after thrombolysis in acute stroke. Neurology 2008; 71 (08) 552-558
• 66 Kellert L, Hametner C, Ahmed N. et al; SITS Investigators. Reciprocal interaction of 24-hour blood pressure variability and systolic blood pressure on outcome in stroke thrombolysis. Stroke 2017; 48 (07) 1827-1834
• 67 Fiehler J, Cognard C, Gallitelli M. et al. European Recommendations on Organisation of Interventional Care in Acute Stroke (EROICAS). Int J Stroke 2016; 11 (06) 701-716
• 68 National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581-1587
• 69 Leonardi-Bee J, Bath PMW, Phillips SJ, Sandercock PAG. IST Collaborative Group. Blood pressure and clinical outcomes in the International Stroke Trial. Stroke 2002; 33 (05) 1315-1320
• 70 Qureshi AI. Acute hypertensive response in patients with stroke: pathophysiology and management. Circulation 2008; 118 (02) 176-187
• 71 Malesker MA, Hilleman DE. Intravenous labetalol compared with intravenous nicardipine in the management of hypertension in critically ill patients. J Crit Care 2012; 27 (05) 528.e7-528.e14
• 72 Farooq MU, Goshgarian C, Min J, Gorelick PB. Pathophysiology and management of reperfusion injury and hyperperfusion syndrome after carotid endarterectomy and carotid artery stenting. Exp Transl Stroke Med 2016; 8 (01) 7
• 73 Aaslid R, Lindegaard KF, Sorteberg W, Nornes H. Cerebral autoregulation dynamics in humans. Stroke 1989; 20 (01) 45-52
• 74 Olsen TS, Larsen B, Herning M, Skriver EB, Lassen NA. Blood flow and vascular reactivity in collaterally perfused brain tissue. Evidence of an ischemic penumbra in patients with acute stroke. Stroke 1983; 14 (03) 332-341
• 75 Petersen NH, Ortega-Gutierrez S, Reccius A, Masurkar A, Huang A, Marshall RS. Dynamic cerebral autoregulation is transiently impaired for one week after large-vessel acute ischemic stroke. Cerebrovasc Dis 2015; 39 (02) 144-150
• 76 Cole DJ, Schell RM, Drummond JC, Patel PM, Marcantonio S. Focal cerebral ischemia in rats: effect of phenylephrine-induced hypertension during reperfusion. J Neurosurg Anesthesiol 1992; 4 (02) 78-84
• 77 Smrcka M, Ogilvy CS, Crow RJ, Maynard KI, Kawamata T, Ames III A. Induced hypertension improves regional blood flow and protects against infarction during focal ischemia: time course of changes in blood flow measured by laser Doppler imaging. Neurosurgery 1998; 42 (03) 617-624 , discussion 624–625
• 78 Donnelly J, Aries MJ, Czosnyka M. Further understanding of cerebral autoregulation at the bedside: possible implications for future therapy. Expert Rev Neurother 2015; 15 (02) 169-185
• 79 de Havenon A. Blood pressure variability: an emerging target for risk reduction in the setting of hypertensive emergency. J Clin Hypertens (Greenwich) 2019; 21 (11) 1693-1694
• 80 Hillis AE, Ulatowski JA, Barker PB. et al. A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and subacute stroke. Cerebrovasc Dis 2003; 16 (03) 236-246
• 81 Schwarz S, Georgiadis D, Aschoff A, Schwab S. Effects of induced hypertension on intracranial pressure and flow velocities of the middle cerebral arteries in patients with large hemispheric stroke. Stroke 2002; 33 (04) 998-1004