Department of Anesthesia, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark.
Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.
JAMA Neurol. 2020 May 1;77(5):622-631. doi: 10.1001/jamaneurol.2019.4838.
The optimal blood pressure targets during endovascular therapy (EVT) for acute ischemic stroke (AIS) are unknown.
To study whether procedural blood pressure parameters, including specific blood pressure thresholds, are associated with neurologic outcomes after EVT.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included adults with anterior-circulation AIS who were enrolled in randomized clinical trials assessing anesthetic strategy for EVT between February 2014 and February 2017. The trials had comparable blood pressure protocols, and patients were followed up for 90 days. A total of 3630 patients were initially approached, and 3265 patients were excluded.
Endovascular therapy.
The primary efficacy variable was functional outcome as defined by the modified Rankin Scale (mRS) score at 90 days. Associations of blood pressure parameters and time less than and greater than mean arterial blood pressure (MABP) thresholds with outcome were analyzed.
Of the 365 patients included in the analysis, the mean (SD) age was 71.4 (13.0) years, 163 were women (44.6%), and the median National Institutes of Health Stroke Scale score was 17 (interquartile range [IQR], 14-21). For the entire cohort, 182 (49.9%) received general anesthesia and 183 (50.1%) received procedural sedation. A cumulated period of minimum 10 minutes with less than 70 mm Hg MABP (adjusted OR, 1.51; 95% CI, 1.02-2.22) and a continuous episode of minimum 20 minutes with less than 70 mm Hg MABP (adjusted OR, 2.30; 95% CI, 1.11-4.75) were associated with a shift toward higher 90-day mRS scores, corresponding to a number needed to harm of 10 and 4, respectively. A cumulated period of minimum 45 minutes with greater than 90 mm Hg MABP (adjusted OR, 1.49; 95% CI, 1.11-2.02) and a continuous episode of minimum 115 minutes with greater than 90 mm Hg MABP (adjusted OR, 1.89; 95% CI, 1.01-3.54) were associated with a shift toward higher 90-day mRS scores, corresponding to a number needed to harm of 10 and 6, respectively.
Critical MABP thresholds and durations for poor outcome were found to be MABP less than 70 mm Hg for more than 10 minutes and MABP greater than 90 mm Hg for more than 45 minutes, both durations with a number needed to harm of 10 patients. Mean arterial blood pressure may be a modifiable therapeutic target to prevent or reduce poor functional outcome after EVT.
急性缺血性脑卒中（AIS）血管内治疗期间的最佳血压目标尚不清楚。
研究血管内治疗过程中的血压参数，包括特定的血压阈值，是否与血管内治疗后的神经功能结局相关。
设计、设置和参与者：这是一项回顾性队列研究，纳入了 2014 年 2 月至 2017 年 2 月期间参加评估血管内治疗麻醉策略的随机临床试验的成年人，其为前循环 AIS 患者。这些试验具有相似的血压方案，患者随访 90 天。最初共接触了 3630 名患者，排除了 3265 名患者。
血管内治疗。
主要疗效变量是 90 天时改良 Rankin 量表（mRS）评分定义的功能结局。分析了血压参数和低于和高于平均动脉血压（MABP）阈值时间与结局的关系。
在纳入分析的 365 名患者中，平均（标准差）年龄为 71.4（13.0）岁，163 名为女性（44.6%），国家卫生研究院卒中量表评分中位数为 17（四分位距[IQR]，14-21）。整个队列中，182 名（49.9%）接受全身麻醉，183 名（50.1%）接受程序性镇静。10 分钟内有最低 70mmHg 的 MABP（调整后的比值比，1.51；95%置信区间，1.02-2.22）和 20 分钟内有最低 70mmHg 的 MABP（调整后的比值比，2.30；95%置信区间，1.11-4.75）的累积时间与更高的 90 天 mRS 评分相关，相应的危害比为 10 和 4。45 分钟内有最低 90mmHg 的 MABP（调整后的比值比，1.49；95%置信区间，1.11-2.02）和 115 分钟内有最低 90mmHg 的 MABP（调整后的比值比，1.89；95%置信区间，1.01-3.54）的累积时间与更高的 90 天 mRS 评分相关，相应的危害比为 10 和 6。
发现关键的 MABP 阈值和不良结局的持续时间为 MABP 低于 70mmHg 超过 10 分钟和 MABP 高于 90mmHg 超过 45 分钟，这两个时间点的危害比均为 10 名患者。平均动脉血压可能是一种可调节的治疗靶点，可预防或减少血管内治疗后不良的功能结局。
