A decrease in blood pressure is associated with unfavorable outcome in patients undergoing thrombectomy under general anesthesia

Abstract

Background Up to two-thirds of patients are either dependent or dead 3 months after thrombectomy for acute ischemic stroke (AIS). Loss of cerebral autoregulation may render patients with AIS vulnerable to decreases in mean arterial pressure (MAP). Objective To determine whether a fall in MAP during intervention under general anesthesia (GA) affects functional outcome. Methods This subgroup analysis included patients from the MR CLEAN trial treated with thrombectomy under GA. The investigated variables were the difference between MAP at baseline and average MAP during GA (ΔMAP) as well as the difference between baseline MAP and the lowest MAP during GA (ΔLMAP). Their association with a shift towards better outcome on the modified Rankin Scale (mRS) after 90 days was determined using ordinal logistic regression with adjustment for prognostic baseline variables. Results Sixty of the 85 patients treated under GA in MR CLEAN had sufficient anesthetic information available for the analysis. A greater ΔMAP was associated with worse outcome (adjusted common OR (acOR) 0.95 per point mm Hg, 95% CI 0.92 to 0.99). An average MAP during GA 10 mm Hg lower than baseline MAP constituted a 1.67 times lower odds of a shift towards good outcome on the mRS. For ΔLMAP this association was not significant (acOR 0.97 per mm Hg, 95% CI 0.94 to 1.00, p=0.09). Conclusions A decrease in MAP during intervention under GA compared with baseline is associated with worse outcome. Trial registration number NTR1804; ISRCTN10888758; post-results. BACKGROUND

The influence of blood pressure management on neurological outcome in endovascular therapy for acute ischaemic stroke

“…4 Collectively, the findings from the recent single centre randomised trials suggest that meticulous haemodynamic management with the aim to avoid SBP<140 mm Hg might be an important component in preventing poor outcome after EVT. 4e6 Several retrospective analyses have suggested hypotension and unstable haemodynamics as mechanisms responsible for the negative outcome associated with GA. 7À9,11,14,22 Specifically, decreases in blood pressure below certain thresholds, 9,14 reduction in blood pressure of different magnitudes, 7,22 and measures of blood pressure variability 8,11 have all been reported to influence outcome.…”

“…The DMABP was calculated as the difference between baseline MABP and average of all MABP values throughout the procedure. 11 The ARV was calculated as the mean of the absolute difference between consecutive measurements of SBPs (ARV syst ), diastolic blood pressures (ARVdiast ) and MABP measurements (ARV MABP ). 5,15 Outcome measures and parameters Neurological outcome was determined with the modified Rankin Score (mRS) after 90 days by an independent assessor blinded to randomisation.…”

Single mean arterial blood pressure drops during stroke thrombectomy under general anaesthesia are associated with poor outcome

“…One reason for this could be the greater challenge of blood pressure management during the induction of GA where post-induction hypotension is common due to cardiodepressive and vasodilatory side effects of most anaesthetic agents [7]. There is, however, conflicting evidence whether hypotension during MT is independently related to worse outcome [8][9][10][11][12]. Previous studies on the relation of blood pressure (BP) during MT and outcome also vary in their suggestions of BP target levels and whether absolute BP levels or relative changes in BP from pre-intervention levels are more critical [8,10].…”

“…There is, however, conflicting evidence whether hypotension during MT is independently related to worse outcome [8][9][10][11][12]. Previous studies on the relation of blood pressure (BP) during MT and outcome also vary in their suggestions of BP target levels and whether absolute BP levels or relative changes in BP from pre-intervention levels are more critical [8,10]. The 2018 AHA/ASA stroke guidelines note that BP should be kept ≤ 180/105 mmHg during MT and recommend correction of hypotension and hypovolemia but do not indicate what minimal BP should be maintained [13].…”

Gaining momentum

“…It remains unclear why a procedure performed more quickly than another would not produce better clinical outcomes. The authors cite several factors as possible explanations, including a higher pretreatment modified Rankin Scale score and a greater likelihood of general anesthesia use in the aspiration cohort 9. The latter is the subject of intense debate within the endovascular community.…”