OUTILS d’ÉVALUATION de la DOULEUR à la PHASE AIGUË de l’ACCIDENT VASCULAIRE CÉRÉBRAL : Revue de la Portée (Scoping Review)

International audienceMoins de 50% des patients touchés par les accidents vasculaires cérébraux peuvent utiliser l’EVA ou l’EN, moins de 65% l’EVS. Nous avons souhaité étudier l'origine et le développement, en sus de leurs qualités psychométriques, des différents outils permettant d'évaluer la douleur dans cette population. Nous avons procédé par une cartographie méthodique et non focale de la littérature (revue de la portée) et utiliser l'Outil d’évaluation de l’origine et du développement des questionnaires (EODQ) pour analyser les instruments. 48 écrits ont eté retrouvés présentant ou mobilisant 15 outils d'évaluation. Il s'agit souvent d'outils d’évaluation de la douleur non spécifiques de la phase aiguë de l’AVC, développés pour des populations proches (soins critiques, difficultés à s’exprimer) et il existe une exceptionnelle prise en compte dans le développement initial et l’usage des composantes cognitivo-comportementales et motivo-affectives de l’expérience douloureuse, de la dimension culturelle, du genre

OUTILS d’ÉVALUATION de la DOULEUR à la PHASE AIGUË de l’ACCIDENT VASCULAIRE CÉRÉBRAL : Revue de la Portée (Scoping Review)

International audienceMoins de 50% des patients touchés par les accidents vasculaires cérébraux peuvent utiliser l’EVA ou l’EN, moins de 65% l’EVS. Nous avons souhaité étudier l'origine et le développement, en sus de leurs qualités psychométriques, des différents outils permettant d'évaluer la douleur dans cette population. Nous avons procédé par une cartographie méthodique et non focale de la littérature (revue de la portée) et utiliser l'Outil d’évaluation de l’origine et du développement des questionnaires (EODQ) pour analyser les instruments. 48 écrits ont eté retrouvés présentant ou mobilisant 15 outils d'évaluation. Il s'agit souvent d'outils d’évaluation de la douleur non spécifiques de la phase aiguë de l’AVC, développés pour des populations proches (soins critiques, difficultés à s’exprimer) et il existe une exceptionnelle prise en compte dans le développement initial et l’usage des composantes cognitivo-comportementales et motivo-affectives de l’expérience douloureuse, de la dimension culturelle, du genre

Neutrophil activation in patients treated with endovascular therapy is associated with unfavorable outcomes and mitigated by intravenous thrombolysis

International audienceBackground Accumulating evidence indicates that neutrophil activation (NA) contributes to microvascular thromboinflammation in acute ischemic stroke (AIS) due to a large vessel occlusion. Preclinical data have suggested that intravenous thrombolysis (IVT) before endovascular therapy (EVT) could dampen microvascular thromboinflammation. In this study we investigated the association between NA dynamics and stroke outcome, and the impact of IVT on NA in patients with AIS treated with EVT. Methods A single-center prospective study was carried out, including patients treated with EVT for whom three blood samples (before, within 1 hour, 24 hours post-EVT) were drawn to measure plasma myeloperoxidase (MPO) concentration as a marker of NA. Unfavorable outcome was defined as a modified Rankin score of 3–6 at 3 months. Results Between 2016 and 2020, 179 patients were included. The plasma MPO concentration peaked significantly 1 hour post-EVT (median increase 21.0 ng/mL (IQR −2.1–150)) and returned to pre-EVT baseline values 24 hours after EVT (median change from baseline −0.8 ng/mL (IQR −7.6–6.7)). This peak was strongly associated with unfavorable outcomes at 3 months (aOR 0.53 (95% CI 0.34 to 0.84), P=0.007). IVT before EVT abolished this 1 hour post-EVT MPO peak. Changes in plasma MPO concentration (baseline to 1 hour post-EVT) were associated with unfavorable outcomes only in patients not treated with IVT before EVT (aOR 0.54 (95% CI 0.33 to 0.88, P=0.013). However, we found no significant heterogeneity in the associations between changes in plasma MPO concentration and outcomes. Conclusions A peak in plasma MPO concentration occurs early after EVT and is associated with unfavorable outcomes. IVT abolished the post-EVT MPO peak and may modulate the association between NA and outcomes

Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke (BP-TARGET): a multicentre, open-label, randomised controlled trial

International audienceBACKGROUND: High systolic blood pressure after successful endovascular therapy for acute ischaemic stroke is associated with increased risk of intraparenchymal haemorrhage. However, no randomised controlled trials are available to guide optimal management. We therefore aimed to assess whether an intensive systolic blood pressure target resulted in reduced rates of intraparenchymal haemorrhage compared with a standard systolic blood pressure target. METHODS: We did a multicentre, open-label, randomised controlled trial at four academic hospital centres in France. Eligible individuals were adults (aged ≥18 years) with an acute ischaemic stroke due to a large-vessel occlusion that was successfully treated with endovascular therapy. Patients were randomly assigned (1:1) to either an intensive systolic blood pressure target group (100-129 mm Hg) or a standard care systolic blood pressure target group (130-185 mm Hg), by means of a central web-based procedure, stratified by centre and intravenous thrombolysis use before endovascular therapy. In both groups, the target systolic blood pressure had to be achieved within 1 h after randomisation and maintained for 24 h with intravenous blood pressure lowering treatments. The primary outcome was the rate of radiographic intraparenchymal haemorrhage at 24-36 h and the primary safety outcome was the occurrence of hypotension. Analyses were done on an intention-to-treat basis. BP-TARGET is registered with ClinicalTrials.gov, number NCT03160677, and the trial is closed at all participating sites. FINDINGS: Between June 21, 2017, and Sept 27, 2019, 324 patients were enrolled in the four participating stroke centres: 162 patients were randomly assigned to the intensive target group and 162 to the standard target group. Four (2%) of 162 patients were excluded from the intensive target group and two (1%) of 162 from the standard target group for withdrawal of consent or legal reasons. The mean systolic blood pressure during the first 24 h after reperfusion was 128 mm Hg (SD 11) in the intensive target group and 138 mm Hg (17) in the standard target group. The primary outcome was observed in 65 (42%) of 154 patients in the intensive target group and 68 (43%) of 157 in the standard target group on brain CT within 24-36 h after reperfusion] (adjusted odds ratio 0·96, 95% CI 0·60-1·51; p=0·84). Hypotensive events were not significantly different between both groups and occurred in 12 (8%) of 158 patients in the intensive target and five (3%) of 160 in the standard target group. Mortality within the first week after randomisation occurred in 11 (7%) of 158 patients in the intensive target group and in seven (4%) of 160 in the standard target group. INTERPRETATION: An intensive systolic blood pressure target of 100-129 mm Hg after successful endovascular therapy did not reduce radiographic intraparenchymal haemorrhage rates at 24-36 h as compared with a standard care systolic blood pressure target of 130-185 mm Hg. Notably, these results are applicable to patients with successful reperfusion and systolic blood pressures of more than 130 mm Hg at the end of procedure. Further studies are needed to understand the association between blood pressure and outcomes after reperfusion. FUNDING: French Health Ministry. Copyrigh

Effect of small vessel disease severity on blood pressure management after endovascular therapy in the BP TARGET trial

International audienceBackground and purpose: Acute ischaemic stroke patients with cerebral small vessel disease (CSVD), including cerebral microbleeds (CMBs) and white matter hyperintensities (WMHs), have worse outcomes. The effect was investigated of two blood pressure strategies (intensive vs. standard) and blood pressure variability (BPV) after reperfusion according to CSVD burden in the BP TARGET trial. Methods: Patients with available magnetic resonance imaging at baseline were included. CMBs were described as absent or present and WMH severity was described according to the Fazekas classification (0–1, absent–mild; 2–3, moderate to severe). Outcomes consisted of any intracerebral hemorrhage (ICH) at 24 h and favorable outcome at 90 days (modified Rankin Scale score between 0 and 2). Results: In all, 246 patients were included. The intensive systolic blood pressure target was not associated with lower rates of ICH or favorable outcome according to CSVD subgroups (all p values >0.35). Several BPV parameters were associated with increased odds of ICH in patients with CMBs but not in patients without CMBs (diastolic blood pressure coefficient of variation, odds ratio 2.06, 95% confidence interval [CI] 1.13–3.77, in patients with ≥1 CMB vs. 0.94, 95% CI 0.68–1.31, in patients without CMBs, phet = 0.026). Several diastolic BPV parameters were associated with worse outcomes in patients with severe WMHs but not in patients without WMHs (diastolic blood pressure coefficient of variation, odds ratio 0.32, 95% CI 0.17–0.61, in patients with severe WMHs vs. 1.09, 95% CI 0.67–1.79, in patients without WMHs; phet = 0.003). Conclusion: No effect of the intensive systolic blood pressure management strategy was found on ICH occurrence or functional outcome according to CSVD burden. BPV was associated with higher odds of ICH in patients with CMBs and worse outcome in patients with moderate-to-severe WMHs