Blood Pressure Changes During Mechanical Thrombectomy for Acute Ischemic Stroke Are Associated With Serious Early Treatment Complications: Symptomatic Intracerebral Hemorrhage and Malignant Brain Edema

Abstract

BackgroundSymptomatic intracranial hemorrhage (sICH) and malignant brain edema (MBE) are well-known deleterious endovascular treatment (EVT) complications that some studies found to be associated with postprocedural blood pressure (BP) variability. We aimed to evaluate their association with periprocedural BP changes, including its intraprocedural decrease.MethodsWe retrospectively analyzed the data of 132 consecutive patients that underwent EVT between 1 December 2018 and 31 December 2019, for anterior circulation ischemic stroke. Analyzed predictors of sICH and MBE included non-invasively obtained BP before and 5-min after treatment, intraprocedural relative decreases of BP from baseline, and its post-treatment increases. SICH was defined in accordance with the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria and MBE as brain edema with midline shift on the follow-up imaging. We used binary logistic regression analysis to investigate the association of BP parameters and the incidence of sICH and MBE.ResultsAmong the included patients, 11 (8.3%) developed sICH and 31 (23.5%) MBE. The intraprocedural decrease of mean arterial blood pressure (MAP) was independently associated with MBE occurrence (aOR per 10 mmHg drop from baseline 1.27; 95% CI 1.01–1.60; P = 0.040). Over 40% MAP drop was associated with a higher risk of sICH in the entire cohort (aOR 4.24; 95% CI 1.33–13.51; P = 0.015), but not in the subgroup with successful reperfusion (aOR 2.81; 95% CI 0.64–12.23; P = 0.169). Post-treatment systolic blood pressure (SBP) and MAP elevation above their minimal values during MT are significantly associated with the development of sICH (aOR per 10 mmHg SBP increase 1.78; 95% CI 1.15–2.76; P = 0.010 and aOR per 10 mmHg MAP increase 1.78; 95% CI 1.04–3.03; P = 0.035).ConclusionsIn the anterior circulation ischemic stroke patients relative MAP decrease during EVT is associated with a higher risk of MBE occurrence, and over 40% MAP drop with a higher incidence of both MBE and sICH. Post-treatment elevation of SBP and MAP increased the risk of sICH.

Higher Serum E-Selectin Levels Associated with Malignant Brain Edema after Endovascular Thrombectomy for Ischemic Stroke: A Pilot Study

“…However, our prospective study showed that 22.6% of patients developed MBE, which is similar to data from a retrospective analysis of 130 patients (25.6% of patients with MBE) [5]. Furthermore, previous clinical studies have found several predictive factors for the presence of MBE in patients following EVT [5,6,25,26]. These factors included advanced age, fasting blood glucose, hypertension, baseline NIHSS score, ASPECT score, collateral score, and unsuccessful recanalization.…”

Predictors for hemorrhagic transformation and cerebral edema in stroke patients with first-pass complete recanalization

“…Interaction between general anesthesia and collateral flow in the reperfusion injury through blood pressure changes and progression of penumbra to ischemic core is complex and not fully understood. [16][17][18] Every efforts should be made to define the best intra-and post-operative hemodynamic management during anesthesia in a special setting such as the one of patients obtaining first-pass complete recanalization. Procedure time is influenced by a significant large number of variables, including those related to stroke etiology, such as clot composition, length, and shape.…”

Association between Transient-Continuous Hypotension during Mechanical Thrombectomy for Acute Ischemic Stroke and Final Infarct Volume in Patients with Proximal Anterior Circulation Large Vessel Occlusion

“…It is hypothesized that a lower systemic BP prior to symptomatic vessel recanalization limits collateral flow and perfusion of penumbral tissue, leading to larger post-intervention infarct volumes and poorer functional treatment results [7,8]. Recently, one study showed that intraprocedural hypotension can lead to serious EVT treatment complications, such as malignant brain edema and symptomatic intracranial hemorrhage, which may be further mediators of worse clinical outcomes [9].…”