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

Abstract

BackgroundStudies on the role of blood pressure (BP) variability specifically during mechanical thrombectomy (MT) are sparse and limited. Moreover, pulse pressure (PP) has not been considered as a potent hemodynamic parameter to describe BP variability during MT. We assessed the impact of PP variability on functional outcome in acute ischemic stroke patients with large vessel occlusion during MT.Methods and ResultsAcute ischemic stroke patients presenting with large vessel occlusion from January 2012 to June 2016 were included. BP data during MT were prospectively collected in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Logistic regression models were used to assess the association between PP coefficients of variation and functional outcome at 3 months (modified Rankin Scale). Among the 343 included patients, PP variability was significantly associated with worse 3‐month modified Rankin Scale in univariable (odds ratio [OR]=1.56, 95% confidence interval [CI]: 1.24–1.96 per 1‐unit increase, P=0.0002) and multivariable ordinal logistic regression (adjusted OR=1.40, 95% CI: 1.09–1.79, P=0.008). PP variability was also associated with unfavorable outcome (modified Rankin Scale 3–6) in univariable (OR=1.53, 95% CI: 1.17–2.01, P=0.002) and multivariable analysis (adjusted OR=1.42, 95% CI: 1.02–1.98, P=0.04). There was an association between PP variability and 3‐month all‐cause mortality in univariable analysis (OR= 1.37, 95% CI: 1.01–1.85 per 1‐unit increase of the coefficient of variation of the PP, P=0.04), which did not remain significant after adjustment for potential confounders.Conclusions PP variability during MT is an independent predictor of worse clinical outcome in acute ischemic stroke patients. These findings support the need for a close monitoring of BP variability during MT. Whether pharmacological interventions aiming at reducing BP variability during MT could impact functional outcome needs to be determined.

Intracranial Hemorrhage After Reperfusion Therapies in Acute Ischemic Stroke Patients

“…sICH rates were not significantly related to baseline systolic or diastolic blood pressure (93). Systolic, pulse pressure and mean arterial BP variability during EVT seem to be critically associated with functional outcome (91,92,(95)(96)(97)(98), but data are scarce regarding the association of blood pressure variability during EVT and sICH risk. After EVT, and notably after complete reperfusion, blood pressure variability seems associated with increased rates of sICH (99,100).…”

“…Numerous studies have recently highlighted the impact of systolic blood pressure in the early phase of AIS treated by EVT (90)(91)(92)(93). The MRCLEAN investigators have found higher systolic BP before EVT associated with increased probability of sICH (94).…”

A 10% blood pressure drop from baseline during mechanical thrombectomy for stroke is strongly associated with worse neurological outcomes

“…However, this threshold comes from exclusion criteria of intravenous thrombolysis trials and randomized controlled trials are still lacking to substantiate this position in the setting of LVO. Indeed, decreases in BP below certain thresholds before recanalization (ie, mean arterial pressure (MAP) <70 or 85 mmHg before reperfusion,13–15systolic blood pressure (SBP) <140 mmHg),16 reductions in BP of different magnitudes (≥10% or 40% MAP drop from baseline14 17) and BP variability18 19 have all been associated with worse functional outcomes 15. However, it still remains unclear whether the relationship between the duration of arterial hypotension during MT and the functional outcome is linear and if this relationship is the same under GA and CS.…”

Blood Pressure Management in Acute Ischemic Stroke

“…In a study by Lowhagen Henden et al, a mean BP (MBP) fall of > 40% from the baseline was an independent predictor of an unfavorable neurological outcome, in addition to well-established risk factors such as a high baseline NIH Stroke Scale (NIHSS) or a lack of successful recanalization [80]. The results have been confirmed by more recent studies [81,82].…”