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Research ArticleNeurointervention

Even Small Decreases in Blood Pressure during Conscious Sedation Affect Clinical Outcome after Stroke Thrombectomy: An Analysis of Hemodynamic Thresholds

M.K. Whalin, K.M. Halenda, D.C. Haussen, L.C. Rebello, M.R. Frankel, R.Y. Gershon and R.G. Nogueira
American Journal of Neuroradiology February 2017, 38 (2) 294-298; DOI: https://doi.org/10.3174/ajnr.A4992
M.K. Whalin
aFrom the Departments of Anesthesiology (M.K.W., R.Y.G.)
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K.M. Halenda
cDiscovery Program (K.M.H.), Emory University School of Medicine, Atlanta, Georgia
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D.C. Haussen
bNeurology (D.C.H., L.C.R., M.R.F., R.G.N.)
dthe Marcus Stroke and Neuroscience Center (D.C.H., L.C.R., M.R.F., R.G.N.), Grady Memorial Hospital, Atlanta, Georgia.
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L.C. Rebello
bNeurology (D.C.H., L.C.R., M.R.F., R.G.N.)
dthe Marcus Stroke and Neuroscience Center (D.C.H., L.C.R., M.R.F., R.G.N.), Grady Memorial Hospital, Atlanta, Georgia.
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M.R. Frankel
bNeurology (D.C.H., L.C.R., M.R.F., R.G.N.)
dthe Marcus Stroke and Neuroscience Center (D.C.H., L.C.R., M.R.F., R.G.N.), Grady Memorial Hospital, Atlanta, Georgia.
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R.Y. Gershon
aFrom the Departments of Anesthesiology (M.K.W., R.Y.G.)
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R.G. Nogueira
bNeurology (D.C.H., L.C.R., M.R.F., R.G.N.)
dthe Marcus Stroke and Neuroscience Center (D.C.H., L.C.R., M.R.F., R.G.N.), Grady Memorial Hospital, Atlanta, Georgia.
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    Fig 1.

    Receiver operating characteristic curves for changes in MAP before modified TICI 2b/3 reperfusion. Curves are shown for the effect of the lowest MAP on 90-day mRS 0–2 (A) and for the relationship between mRS 3–6 and an absolute MAP drop (B) and percentage MAP drop (C). The curves are labeled with pressures (A and B, in millimeters of mercury) and percentages (C). The cutoffs that were independent predictors of outcome in binary regression models are shown with bold type and open block arrows. AUC indicates area under the curve.

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    Fig 2.

    Rates of good neurologic outcome (90-day mRS of 0–2) by baseline NIHSS score and the lowest MAP measured before modified TICI 2b/3 reperfusion. Subdividing the NIHSS groups into 4 MAP categories yielded subgroups of similar size (n = 18–26).

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    Table 1:

    Univariate analysis of baseline characteristics, procedural variables, and outcomes associated with 90-day mRS > 2a

    All Patients (n = 256b)90-Day mRS 0–2 (n = 152)90-Day mRS >2 (n = 104)P Value
    Demographics
        Age (yr)65.2 ± 15.461.5 ± 15.170.7 ± 14.1<.01c
        Male sex123 (48%)76 (50%)47 (46%).49
        Current smoker48 (19%)30 (20%)18 (17%).61
        Hypertension179 (70%)102 (67%)77 (74%).23
        Diabetes mellitus58 (23%)35 (23%)23 (22%).86
        Dyslipidemia92 (36%)55 (36%)37 (36%).92
        Atrial fibrillation95 (37%)49 (32%)46 (44%).06c
    Stroke features
        Baseline NIHSS17 (13–22)15 (11–19)20 (17–24)<.01c
        ASPECTS8 (7–9)9 (7–9)7 (6–9)<.01c
        Occlusion site
            ICA terminus46 (18%)18 (12%)28 (27%)<.01c
            MCA M1158 (72%)98 (64%)60 (58%).27
        Last healthy to puncture (min)295 (219–457)281 (208–460)305 (236–449).34
        IV tPA given113 (44%)71 (47%)42 (41%).35
    Intraprocedural management
        Stent retriever189 (74%)115 (76%)74 (72%).44
        Procedure time (min)62 (41–88)60 (41–81)66 (40–91).23
        Vasopressor use134 (52%)75 (49%)59 (57%).24
    Outcomes
        Parenchymal hemorrhage19 (7%)4 (3%)15 (14%)<.01c
        Final infarct volume (cm3)20.5 (7.3–60.0)13.4 (5.4–35.6)30.6 (17.4–111)<.01
        90-day mRS2 (1–4)
        Mortality31 (12%)31 (30%)
    • Note:—M1 indicates the sphenoidal segment of middle cerebral artery.

    • ↵a Results are shown as mean ± SD, median (interquartile range), or number (percentage).

    • ↵b Not all patients had data available for ASPECTS (n = 243), minutes from last known healthy to groin puncture (n = 211), or final infarct volume (n = 217).

    • ↵c Variables with P < .1 added to the multivariate models.

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    Table 2:

    Intraprocedural hemodynamic characteristicsa and their association with 90-day mRS > 2

    All Patients (n = 256)90-Day mRS 0–2 (n = 152)90-Day mRS > 2 (n = 104)P Valueb
    Systolic blood pressure
        Baseline (mm Hg)158 (135–176)156 (134–173)160 (137–180).137
        Lowest before mTICI 2b/3 (mm Hg)c117 (103–132)118 (105–135)115 (99–124).047
        Absolute drop (mm Hg)d35.5 (17–56)30.0 (11–51)41.5 (24–63).004
        % Pressure drope22.8% (12–34)21.4% (9–32)27.6% (16–37).002
    Mean arterial pressure
        Baseline (mm Hg)107 (95–120)107 (94–118)107 (95–123).473
        Lowest before mTICI 2b/3 (mm Hg)79 (71–89)81 (72–92)77 (68–85).01
        Absolute drop (mm Hg)d24.7 (13–39)23.8 (11–31)26.7 (16–42).008
        % Pressure drope23.3% (13–34)22.1% (12–31)25.6% (18–37).004
    • Note:—mTICI indicates modified TICI.

    • ↵a Reported as median (interquartile range) unless otherwise noted.

    • ↵b Mann-Whitney U test.

    • ↵c Obtained from the systolic component of the lowest observed MAP prior to mTICI 2b/3 reperfusion.

    • ↵d Calculated as the baseline pressure minus the lowest pressure before mTICI 2b/3.

    • ↵e Calculated as the absolute pressure drop divided by the baseline pressure.

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    Table 3:

    Binary logistic regression model for poor neurologic outcome (90-day mRS > 2)a

    VariableOR (95% CI)P Value
    Age1.05 (1.02–1.07).001
    Atrial fibrillation1.09 (0.55–2.15).805
    Baseline NIHSS1.16 (1.09–1.24)<.001
    ASPECTS0.80 (0.65–0.97).023
    ICA terminus occlusion2.50 (1.14–5.50).022
    Parenchymal hemorrhage5.06 (1.30–19.7).020
    Lowest MAP (per 10-mm Hg drop below 100 mm Hg)b1.28 (1.01–1.62).043
    • ↵a Variables with P < .1 in univariate analysis were entered simultaneously into a multivariate logistic regression model.

    • ↵b Lowest intraprocedural MAP recorded prior to mTICI 2b/3 reperfusion.

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American Journal of Neuroradiology: 38 (2)
American Journal of Neuroradiology
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M.K. Whalin, K.M. Halenda, D.C. Haussen, L.C. Rebello, M.R. Frankel, R.Y. Gershon, R.G. Nogueira
Even Small Decreases in Blood Pressure during Conscious Sedation Affect Clinical Outcome after Stroke Thrombectomy: An Analysis of Hemodynamic Thresholds
American Journal of Neuroradiology Feb 2017, 38 (2) 294-298; DOI: 10.3174/ajnr.A4992

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Even Small Decreases in Blood Pressure during Conscious Sedation Affect Clinical Outcome after Stroke Thrombectomy: An Analysis of Hemodynamic Thresholds
M.K. Whalin, K.M. Halenda, D.C. Haussen, L.C. Rebello, M.R. Frankel, R.Y. Gershon, R.G. Nogueira
American Journal of Neuroradiology Feb 2017, 38 (2) 294-298; DOI: 10.3174/ajnr.A4992
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