Mayer, Stephan A

Wartenberg, Katja E

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Henry Ford Health System Henry Ford Health System Scholarly Commons Neurology Articles Neurology 8-8-2017 Determining the optimal target blood pressure after thrombectomy: High or low? Katja E. Wartenberg Stephan A. Mayer Henry Ford Health System Follow this and additional works at: https://scholarlycommons.henryford.com/neurology_articles Recommended Citation Wartenberg KE, and Mayer SA. Determining the optimal target blood pressure after thrombectomy: High or low? Neurology 2017; 89(6):528-529. This Article is brought to you for free and open access by the Neurology at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Neurology Articles by an authorized administrator of Henry Ford Health System Scholarly Commons. EDITORIALKatja E. Wartenberg,MD, PhDStephan A. Mayer, MDCorrespondence toDr. Wartenberg:katja.wartenberg@medizin.uni-halle.deNeurology® 2017;89:528–529See page 540Determining the optimal target bloodpressure after thrombectomyHigh or low?The management of patients with acute ischemicstroke has changed dramatically with modernmechanical thrombectomy (MT) techniques andimproved patient selection using CT angiography.1Although the benefit of early recanalization in largevessel occlusion (LVO) seems clear, the optimal peri-procedural management remains uncertain. Unre-solved issues include the method of analgesia andsedation, reversal and application of adjunctive peri-procedural anticoagulation, glycemic control, ventila-tory management, and perhaps most important,blood pressure (BP) control.Current guidelines inadequately address BP man-agement after MT, given the lack of randomized con-trolled trials.2,3 Observational studies indicate highermortality and greater frequency of neurologic deteri-oration with extremely high or low admission BP, ascompared to when BP falls in a middle range or“sweet spot.”4 Retrospective analyses have linkedlarger anesthesia-related reductions in BP during theMT procedure with poor outcome, whether generalanesthesia5,6 or conscious sedation.7 Another studyfound an association between intraproceduralanesthesia-related hypotension treated with IV nor-epinephrine and poor functional outcome after MT.8Data regarding BP management after MT are evenmore scant.In this issue of Neurology®, Goyal et al.9 report therelationship of maximum BP levels after MT andlong-term functional independence in 217 patientswith acute ischemic stroke due to LVO in the anterioror posterior circulation. All patients underwentmechanical recanalization through a combination ofstent retriever deployment with or without distal aspi-ration, first pass direct aspiration, or angioplasty andstenting within 8 hours of symptom onset. Sixty-fivepercent of patients received systemic thrombolysisprior to intervention. All data were collected prospec-tively, including hourly BP values.Sixty-five percent of patients achieved completerecanalization (Thrombolysis in Cerebral Infarction[TICI] score of 2B or 3). The authors evaluated 3groups according to the BP goal and thrombolysisstatus: (1) permissive hypertension (220/120 mmHg without systemic thrombolysis or ,180/90 mmHg with systemic thrombolysis); (2) moderate BPcontrol (,160/90 mm Hg); and (3) intensive BPcontrol (,140/90 mmHg) based on American HeartAssociation guidelines,2 institutional practice stand-ards, and physician preference. They constructedmultivariable models to determine the relationshipbetween minimum, maximum, and mean systolicand diastolic BP levels during the first 24 hours afterMT and functional independence (defined as a mod-ified Rankin Scale score of 0–2) and mortality at 3months.Overall, 45% of patients achieved functional inde-pendence at 3 months, 26% died, and 6.5% experi-enced a symptomatic intracranial hemorrhage. Ina univariate analysis, those with lower maximum sys-tolic and diastolic BP levels 24 hours after the inter-vention—163 6 20 vs 179 6 23 mm Hg systolic,and 90 6 15 vs 97 6 14 mm Hg diastolic—hadgreater likelihood of 3-month functional indepen-dence. Similarly, those with higher postproceduremaximum systolic and diastolic BP levels had highermortality. Despite the perceived risk of reperfusioninjury after recanalization, there was no associationbetween maximum systolic and diastolic BP levelsand symptomatic intracranial hemorrhage. Meanand minimum BP levels did not have an effect onany of the outcomes. In multivariable analysis, anincrement of 10 mm Hg in maximum systolic BPwas independently associated with a lower likelihoodof functional independence and a higher mortalityrate at 3 months. Among the 140 patients with com-plete reperfusion, those undergoing permissive hyper-tension as a BP target had a higher 3-month mortalityrate and lower frequency of functional independence.The moderate BP goal of ,160/90 mm Hg wasindependently linked to lower mortality at 3 monthscompared to permissive hypertension.In contrast to the cited previous data suggestingthat higher BP levels are desirable during the MT pro-cedure, the data presented by Goyal et al.9 suggestthat lower BP targets are desirable during the firstFrom the Department of Neurology (K.E.W.), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany; and Department of Neurology(S.A.M.), Neuroscience Institute, Henry Ford Health System, Detroit, MI.Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the editorial.528 © 2017 American Academy of Neurologyª 2017 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.24 hours after established reperfusion. Accounting forthe available data, given the choice of targeting sys-tolic BP ,180, ,160, or ,140 mm Hg for the first24 hours after a successful MT procedure, taking themiddle road with an order to maintain systolic BP,160 mm Hg using a continuous infusion calciumchannel blocker such as nicardipine or clevidipineseems a prudent default strategy until higher-qualitydata are available.The reader must understand that these data,although provocative, are far from definitive andmay actually prove misleading. As a retrospectiveanalysis of prospectively collected data at a singleinstitution with its own standards and treatment pro-tocols, the data have a substantial risk for confound-ing due to treatment allocation bias: the possibilitythat an unmeasured variable explained both the deci-sion to select a higher BP target and the poor out-comes that occurred. In this case, the relative extentof incomplete downstream hypoperfusion on thepostthrombectomy angiogram is the most likely con-founding variable. Full recanalization has consistentlydemonstrated better outcomes after LVO.1 Similarly,based on our experience, the most common rationalefor selecting a higher BP target after MT is the pres-ence of persistent primary or distal vessel occlusionwith dependence on collaterals. Both subtle and overtdegrees of incomplete downstream microvascular re-perfusion, not captured by the TICI scale by thetreating team, may lead to overrepresentation in thepermissive hypertension group. Only a prospectiverandomized trial can truly resolve this issue and deter-mine the optimal target BP after MT.The mechanism of death among the 29% of pa-tients treated with permissive hypertension who died(compared to 0% and 8% in the intensive and mod-erate BP target groups) needs clarification. Hemor-rhagic transformation does not explain the excessmortality: the intensive BP-lowering group had thehighest rate of hemorrhagic transformation and thelowest zero mortality. We encourage the authors tofollow up on this in a secondary analysis.These new data from Goyal et al. add helpful pre-liminary information to a previously evidence-freezone. Given the available data, treating severe hyper-tension after MT with a target of maintaining SBP,160 mm Hg seems prudent. This target mayrequire adjustment after accounting for the finaldegree of downstream recanalization and quality ofcollaterals, baseline BP, use of thrombolytic therapy,and cardiac and renal function. Future researchfocusing on assessment of autoregulation and theeffect of BP variability (as opposed to the mean value)may help. Ultimately, however, a prospective, ran-domized trial will need to determine the optimalBP management strategy.STUDY FUNDINGNo targeted funding reported.DISCLOSUREK.E. Wartenberg received speaker’s honoraria for participation in anadvisory board from Boehringer Ingelheim and for lectures from BardMedical. S.A. Mayer is a consultant for Stryker Neurovascular. Go toNeurology.org for full disclosures.REFERENCES1. Goyal N, Menon BK, van Zwam WH, et al. Endovascularthrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomisedtrials. Lancet 2016;387:1723–1731.2. Jauch EC, Saver JL, Adams HP Jr, et al; American HeartAssociation Stroke Council, Council on CardiovascularNursing, Council on Peripheral Vascular Disease, Councilon Clinical Cardiology. Guidelines for the early manage-ment of patients with acute ischemic stroke: a guidelinefor healthcare professionals from the American HeartAssociation/American Stroke Association. Stroke 2013;44:870–947.3. Powers WJ, Derdeyn CP, Biller J, et al. 2015 AmericanHeart Association/American Stroke Association focusedupdate of the 2013 guidelines for the early managementof patients with acute ischemic stroke regarding endovascu-lar treatment: a guideline for healthcare professionals fromthe American Heart Association/American Stroke Associa-tion. Stroke 2015;46:3024–3039.4. Rose JC, Mayer SA. Optimizing blood pressure in neuro-logical Emergencies. Neurocrit Care 2004;1:287–299.5. Treurniet KM, Berkhemer OA, Immink RV, et al. Adecrease in blood pressure is associated with unfavorableoutcome in patients undergoing thrombectomy undergeneral anesthesia. J Neurointerv Surg 2016;8:1101–1106.6. Jagani M, Brinjikji W, Rabinstein AA, Pasternak JJ,Kallmes DF. Hemodynamics during anesthesia for intra-arterial therapy of acute ischemic stroke. J Neurointerv Surg2016;8:883–888.7. Whalin MK, Halenda KM, Haussen DC, et al. Even smalldecreases in blood pressure during conscious sedationaffect clinical outcome after stroke thrombectomy: ananalysis of hemodynamic thresholds. Am J Neuroradiol2017;38:294–298.8. Mundiyanapurath S, Stehr A, Wolf M, et al. Pulmonaryand circulatory parameter guided anesthesia in patients withischemic stroke undergoing endovascular recanalization.J Neurointerv Surg 2016;8:335–341.9. Goyal N, Tsivgoulis G, Pandhi A, et al. Blood pressurelevels post mechanical thrombectomy and outcomes in largevessel occlusion strokes. Neurology 2017;89:540–547.Neurology 89 August 8, 2017 529ª 2017 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

Determining the optimal target blood pressure after thrombectomy: High or low?

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Determining the optimal target blood pressure after thrombectomy: High or low?

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