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Good outcome associated with blood-brain barrier disruption and lower blood pressure after endovascular therapy

  • Parth Upadhyaya
    Correspondence
    Corresponding author.
    Affiliations
    Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA
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  • Amit Mehta
    Affiliations
    Department of Neurology, Georgetown University School of Medicine, Washington, D.C., USA
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  • Marie Luby
    Affiliations
    Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA
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  • Saeed Ansari
    Affiliations
    Department of Neurology, Inova Health, Fairfax, VA, USA
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  • John K Lynch
    Affiliations
    Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA
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  • Amie W Hsia
    Affiliations
    Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA

    Department of Neurology, Georgetown University School of Medicine, Washington, D.C., USA

    Comprehensive Stroke Center, MedStar Washington Hospital Center, Washington, D.C., USA
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  • Lawrence L Latour
    Affiliations
    Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA
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  • Yongwoo Kim
    Affiliations
    Stroke Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Dr., Building 10, Room B1D733, Bethesda, MD 20892, USA

    Department of Neurology, Georgetown University School of Medicine, Washington, D.C., USA

    Comprehensive Stroke Center, MedStar Washington Hospital Center, Washington, D.C., USA
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      Abstract

      Objectives

      To evaluate the association between post-endovascular thrombectomy (EVT) blood-brain barrier (BBB) disruption on MRI or CT and average systolic blood pressure (SBP) with favorable 90-day functional outcome. Observational studies have found elevated SBP associated with worse outcomes post-EVT, while recent randomized trials found no difference in targeted BP reduction. There may be a subgroup of patients who benefit from targeted BP reduction post-EVT.

      Methods

      This is a single-center study of 1) anterior large vessel occlusion stroke patients treated with EVT from 2015 to 2021, 2) achieved mTICI grade 2b or 3. Hyperintense acute reperfusion marker (HARM), hemorrhagic transformation (HT), and midline shift at 3 h post-EVT and 24 h imaging were assessed independently by multiple raters. Binary logistic regression models were used to determine the association of post-EVT SBP with outcomes. BBB disruption was defined as HT or HARM on 3h post-EVT imaging.

      Results

      Of 103 patients, those with SBP 100-129 versus SBP 130-160 found no significant difference in favorable 90-day outcome (64% vs. 46%, OR 2.11, 95% CI 0.78-5.76, p=0.143). However, among 71 patients with BBB disruption, a significant difference in favorable outcome of 64% in SBP 100-129 vs. 39% in SBP 130-160 group (OR 5.93, 95% CI 1.50-23.45, p=0.011) was found. There was no difference in symptomatic ICH, 90-day mortality, midline shift (≥5 mm), and hemicraniectomy, between BP or BBB groups.

      Conclusions

      BBB disruption on 3h post-EVT imaging and lower SBP was associated with favorable outcome. This imaging finding may guide targeted BP therapy and suggests need for a randomized control trial.

      Keywords

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      References

        • Peng T.J.
        • Ortega-Gutiérrez S.
        • Havenon A.
        • Petersen N.H.
        Blood pressure management after endovascular thrombectomy.
        Front Neurol. 2021; 12723461
        • Huang X.
        • Guo H.
        • Yuan L.
        • et al.
        Blood pressure variability and outcomes after mechanical thrombectomy based on the recanalization and collateral status.
        Ther Adv Neurol Disord. 2021; 141756286421997383
        • Mistry E.A.
        • Mehta T.
        • Mistry A.
        • et al.
        Blood pressure variability and neurologic outcome after endovascular thrombectomy.
        Stroke. 2020; 51: 511-518
        • Mistry E.A.
        • Mistry A.M.
        • Nakawah M.O.
        • et al.
        Systolic blood pressure within 24 hours after thrombectomy for acute ischemic stroke correlates with outcome.
        J Am Heart Assoc. 2017; 6e006167
        • McCarthy D.J.
        • Ayodele M.
        • Luther E.
        • et al.
        Prolonged heightened blood pressure following mechanical thrombectomy for acute stroke is associated with worse outcomes.
        Neurocrit Care. 2020; 32: 198-205
        • Anadani M.
        • Arthur A.S.
        • Tsivgoulis G.
        • et al.
        Blood pressure goals and clinical outcomes after successful endovascular therapy: a multicenter study.
        Ann Neurol. 2020; 87: 830-839
        • Goyal N.
        • Tsivgoulis G.
        • Pandhi A.
        • et al.
        Blood pressure levels post mechanical thrombectomy and outcomes in non-recanalized large vessel occlusion patients.
        J Neurointerv Surg. 2018; 10: 925
        • Powers W.J.
        • Rabinstein A.A.
        • Ackerson T.
        • et al.
        Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2019; 50: e365
        • Mazighi M.
        • Richard S.
        • Lapergue B.
        • et al.
        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.
        Lancet Neurol. 2021; 20: 265-274
        • Yang C.
        • Hawkins K.E.
        • Doré S.
        • Candelario-Jalil E.
        Neuroinflammatory mechanisms of blood-brain barrier damage in ischemic stroke.
        Am J Physiol Cell Physiol. 2019; 316: C135-C153
        • D'Souza A.
        • Dave K.M.
        • Stetler R.A.
        • Manickam D.S.
        Targeting the blood-brain barrier for the delivery of stroke therapies.
        Adv Drug Deliv Rev. 2021; 171: 332-351
        • Jiang X.
        • Andjelkovic A.V.
        • Zhu L.
        • et al.
        Blood-brain barrier dysfunction and recovery after ischemic stroke.
        Prog Neurobiol. 2018; 163: 144-171
        • Hoffmann A.
        • Zhu G.
        • Wintermark M.
        Advanced neuroimaging in stroke patients: prediction of tissue fate and hemorrhagic transformation.
        Expert Rev Cardiovasc Ther. 2014; 10: 515-524
        • Avsenik J.
        • Bisdas S.
        • Popovic K.S.
        Blood-brain barrier permeability imaging using perfusion computed tomography.
        Radiol Oncol. 2015; 49: 107-114
        • Starling E.H.
        On the absorption of fluids from the connective tissue spaces.
        J Physiol. 1896; 19: 312-326
        • Larsen F.S.
        • Wendon J.
        Brain edema in liver failure: Basic physiologic principles and management.
        Liver Transplt. 2002; 8: 983-989
        • Luby M.
        • Merino J.G.
        • Davis R.
        • et al.
        Association of multiple passes during mechanical thrombectomy with incomplete reperfusion and lesion growth.
        Cerebrovasc Dis. 2022; 51: 394-402
        • Straka M.
        • Albers G.W.
        • Bammer R.
        Real-time diffusion-perfusion mismatch analysis in acute stroke.
        J Magn Reson Imaging. 2010; 32: 1024-1037
        • Warach S.
        • Latour L.L.
        Evidence of reperfusion injury, exacerbated by thrombolytic therapy, in human focal brain ischemia using a novel imaging marker of early blood–brain barrier disruption.
        Stroke. 2004; 35: 2659-2661
        • Liao C.C.
        • Chen Y.F.
        • Xiao F.
        Brain midline shift measurement and its automation: a review of techniques and algorithms.
        Int J Biomed Imaging. 2018; 20184303161
        • Bullock M.R.
        • Chesnut R.
        • Ghajar J.
        • et al.
        Surgical management of traumatic parenchymal lesions.
        Neurosurgery. 2006; 58: S2.25-S2.46
        • Latour L.L.
        • Kang D.
        • Ezzeddine M.A.
        • Chalela J.A.
        • Warach S.
        Early blood–brain barrier disruption in human focal brain ischemia.
        Ann Neurol. 2004; 56: 468-477
        • Ostwaldt A.C.
        • Rozanski M.
        • Schmidt W.U.
        • et al.
        Early time course of FLAIR signal intensity differs between acute ischemic stroke patients with and without hyperintense acute reperfusion marker.
        Cerebrovasc Dis. 2014; 37: 141-146
        • Lee K.M.
        • Kim J.H.
        • Kim E.
        • Choi B.S.
        • Bae Y.J.
        • Bae H.J.
        Early stage of hyperintense acute reperfusion marker on contrast-enhanced FLAIR images in patients with acute stroke.
        Am J Roentgenol. 2016; 206: 1272-1275
        • Förster A.
        • Wenz H.
        • Groden C.
        Hyperintense acute reperfusion marker on FLAIR in a patient with transient ischemic attack.
        Case Rep Radiol. 2016; 20169829823
        • Koenigsberg R.A.
        • Gul N.
        • Faro S.
        • Elfont R.
        • Baker K.
        • Tsai F.
        Hyperacute cerebral enhancement: the earliest predictor of hemorrhage by MR imaging?.
        J Neuroimaging. 1999; 9: 235-236
        • Gupta R.
        • Sun C.H.J.
        • Rochestie D.
        • et al.
        Presence of the hyperintense acute reperfusion marker on MRI after mechanical thrombectomy for large vessel occlusion is associated with worse early neurological recovery.
        J Neurointerv Surg. 2017; 9: 641
        • Bernardo-Castro S.
        • Sousa J.A.
        • Brás A.
        • et al.
        Pathophysiology of blood–brain barrier permeability throughout the different stages of ischemic stroke and its implication on hemorrhagic transformation and recovery.
        Front Neurol. 2020; 11594672
        • Simard J.M.
        • Kent T.A.
        • Chen M.
        • Tarasov K.V.
        • Gerzanich V.
        Brain oedema in focal ischaemia: molecular pathophysiology and theoretical implications.
        Lancet Neurol. 2007; 6: 258-268
        • Immink R.V.
        • Montfrans G.A.
        • Stam J.
        • Karemaker J.M.
        • Diamant M.
        • Lieshout J.J.
        Dynamic cerebral autoregulation in acute lacunar and middle cerebral artery territory ischemic stroke.
        Stroke. 2005; 36: 2595-2600
        • Reinhard M.
        • Rutsch S.
        • Lambeck J.
        • et al.
        Dynamic cerebral autoregulation associates with infarct size and outcome after ischemic stroke.
        Acta Neurol Scand. 2012; 125: 156-162
        • Reinhard M.
        • Wihler C.
        • Roth M.
        • et al.
        Cerebral autoregulation dynamics in acute ischemic stroke after rtPA thrombolysis.
        Cerebrovasc Dis. 2008; 26: 147-155
        • Petersen N.H.
        • Ortega-Gutierrez S.
        • Reccius A.
        • Masurkar A.
        • Huang A.
        • Marshall R.S.
        Dynamic cerebral autoregulation is transiently impaired for one week after large-vessel acute ischemic stroke.
        Cerebrovasc Dis. 2015; 39: 144-150