Baseline Blood Pressure Effect on the Benefit and Safety of Intra-Arterial Treatment in MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands)

Abstract

Background and Purpose— High blood pressure (BP) is associated with poor outcome and the occurrence of symptomatic intracranial hemorrhage in acute ischemic stroke. Whether BP influences the benefit or safety of intra-arterial treatment (IAT) is not known. We aimed to assess the relation of BP with functional outcome, occurrence of symptomatic intracranial hemorrhage and effect of IAT. Methods— This is a post hoc analysis of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands). BP was measured at baseline, before IAT or stroke unit admission. We estimated the association of baseline BP with the score on the modified Rankin Scale at 90 days and safety parameters with ordinal and logistic regression analysis. Effect of BP on the effect of IAT was tested with multiplicative interaction terms. Results— Systolic BP (SBP) had the best correlation with functional outcome. This correlation was U-shaped; both low and high baseline SBP were associated with poor functional outcome. Higher SBP was associated with symptomatic intracranial hemorrhage (adjusted odds ratio, 1.25 for every 10 mm Hg higher SBP [95% confidence interval, 1.09–1.44]). Between SBP and IAT, there was no interaction for functional outcome, symptomatic intracranial hemorrhage, or other safety parameters; the absolute benefit of IAT was evident for the whole SBP range. The same was found for diastolic BP. Conclusions— BP does not affect the benefit or safety of IAT in patients with acute ischemic stroke caused by proximal intracranial vessel occlusion. Our data provide no arguments to withhold or delay IAT based on BP. Clinical Trial Registration— URL: http://www.isrctn.com . Unique identifier: ISRCTN10888758.

High Systolic Blood Pressure after Successful Endovascular Treatment Affects Early Functional Outcome in Acute Ischemic Stroke

“…However, this threshold is based on the theoretical assumption that moderate arterial hypertension during acute ischemic stroke might be advantageous by improving cerebral perfusion of the ischemic penumbra in an unselected population of stroke patients without distinction between patients with and without successful reperfusion [2]. Two recent studies including patients from the MR CLEAN trial [6] and using a prospectively derived database of patients with IVT for large vessel occlusion strokes [7] showed a relationship between high admission SBP and poor functional outcome. These studies, however, do not answer the question on how blood pressure management should be performed after successful EVT.…”

Blood Pressure in Acute Stroke

“…1 Goyal et al 22 have shown that higher admission SBP is an independent predictor of increased final infarct volume and a lower likelihood of favorable functional outcome in patients with large-vessel occlusion treated with EVT. However, given the overall poor evidence of BP management in patients with ischemic stroke and given the pathophysiological considerations mentioned above, active BP lowering in acute stroke patients with proximal vessel occlusion before recanalization might be harmful.…”

“…The post hoc analysis of data of the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) published in Stroke adds important new information about the risks and benefits of endovascular therapy (EVT) in acute stroke patients with different BP levels at baseline. Mulder et al 1 analyzed BP and the effect of EVT in the MR CLEAN study and showed that the effectiveness of EVT is similar in the entire range of baseline BP of the included patients. Furthermore, BP and EVT did not interact with the occurrence of symptomatic intracerebral hemorrhage (ICH) or other safety parameters.…”

“…BP thresholds for IVT candidates were established during the NINDS pilot study (National Institute of Neurological Disorders and Stroke) and are based on thrombolysis databases showing baseline hypertension as a risk factor for parenchymal hemorrhage. 1,15 Furthermore, there is an association of elevated BP levels with the reduced likelihood of recanalization in patients with stroke treated with IVT. 16 However, data on BP lowering before IVT are conflicting.…”

Prognostic Significance of Pulse Pressure Variability During Mechanical Thrombectomy in Acute Ischemic Stroke Patients

“…Recent evidence supports the impact of baseline systolic blood pressure (SBP) on mortality and functional outcome at 3 months in MT treated patients,2, 3 but data on the role of BP variability specifically during the procedure are sparse and limited. The definition of BP variability often differs across studies and the main hemodynamic parameters measured are SBP and mean arterial pressure 4.…”