Association of Blood Pressure During Thrombectomy for Acute Ischemic Stroke With Functional Outcome

A Systematic Review

Benjamin Maïer, MD, MSc; Robert Fahed, MD, MSc; Naim Khoury, MD; Adrien Guenego, MD, MSc; Julien Labreuche, BST; Guillaume Taylor, MD; Jacques Blacher, MD, PhD; Mathieu Zuber, MD, PhD; Bertrand Lapergue, MD, PhD; Raphaël Blanc, MD; Michel Piotin, MD, PhD; Mikael Mazighi, MD, PhD

Disclosures

Stroke. 2019;50(10):2805-2812. 

In This Article

Abstract and Introduction

Abstract

Background and Purpose: Optimal blood pressure (BP) targets during mechanical thrombectomy (MT) for acute ischemic stroke (AIS) are unknown, and randomized controlled trials addressing this issue are lacking. We aimed to perform a systematic review of studies evaluating the influence of periprocedural BP on functional outcome after MT.

Methods: Studies assessing periprocedural BP effect on functional outcome published after January 1st, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work.

Results: Nine studies were included, for a total of 1037 patients. The heterogeneity in findings with respect to BP monitoring and studied parameters precluded a meta-analysis. Mean arterial pressure was the most frequently reported parameter to describe BP variability during MT, and systolic BP was the main parameter used to define periprocedural BP targets. Five studies suggested an association between 3 types of BP drops as predictors of poor functional outcome at 3 months: >40% drop in mean arterial pressure compared with baseline (odds ratio=2.8; [1.09–7.19]; P=0.032), lowest mean arterial pressure before recanalization (odds ratio=1.28; [1.01–1.62] per 10 mm Hg drop below 100 mm Hg; P=0.04), and MAP drops (odds ratio=4.38; [1.53–12.6] for drops >10%). Four studies did not show an association between BP during MT and functional outcome, including 3 studies with strict periprocedural systolic BP targets (within a 140–180 mm Hg).

Conclusions: BP drops during MT may be associated with a worse functional outcome. When strict systolic BP targets are achieved, no association between BP and functional outcome was also noted. Both conclusions require further evaluation in randomized studies.

Introduction

Mechanical thrombectomy (MT) is now the standard of care for patients with acute ischemic stroke and large vessel occlusion (LVO) in the anterior circulation.[1,2] Although recent studies achieved higher recanalization rates owing to technological improvements, more than 50% of patients do not regain functional independence at 3 months despite a successful recanalization within 6 hours.[1]

Blood pressure (BP) is a critical prognosis factor in acute ischemic stroke (AIS) patients. Several studies describing the effect of BP pre-,[3–5] during[6–18] and following MT[19–21] on functional outcome suggest an association between high and low presenting systolic BP (SBP) and increased rates of morbidity and mortality,[3,4] as well as a negative impact of BP variability during MT on functional outcome.[6] BP management might differ according to individual patient hypertension history (hypertensive patients being more prone to a heightened hypertensive response and more vulnerable to larger drops with fast and intensive BP reduction due to the rightward shift of the brain auto-regulation curve[22,23]) or to sedation modality (general anesthesia [GA] versus conscious sedation [CS]). The specific pharmacological effect of each vasopressor or BP-lowering drug in the setting of LVO remains to be determined, as the chosen therapeutic strategy is often at the discretion of the physician in charge. Periprocedural BP management strategies have not been evaluated in randomized controlled trials (RCTs), and the current BP targets defined in the European[24] or American guidelines[2] are based on limited studies with heterogeneous methods (ie, BP targets and parameters).

We, therefore, aimed to perform a systematic review of available recent studies addressing the effects of periprocedural BP during MT on functional outcome in AIS patients with LVO.

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