Silverman Andrew, Kodali Sreeja, Sheth Kevin N, Petersen Nils H
Department of Neurology, Yale School of Medicine, New Haven, CT, United States.
Front Neurol. 2020 Jul 17;11:728. doi: 10.3389/fneur.2020.00728. eCollection 2020.
Hemorrhagic transformation remains a potentially catastrophic complication of reperfusion therapies for the treatment of large-vessel occlusion ischemic stroke. Observational studies have found an increased risk of hemorrhagic transformation in patients with elevated blood pressure as well as a high degree of blood pressure variability, suggesting a link between hemodynamics and hemorrhagic transformation. Current society-endorsed guidelines recommend maintaining blood pressure below a fixed threshold of 180/105 mmHg regardless of thrombolytic or endovascular intervention. However, given the high recanalization rates with mechanical thrombectomy, it is unclear if the same hemodynamic goals from the pre-thrombectomy era apply. Also, individual patient factors such as the degree of reperfusion, infarct size, and collateral status likely need to be considered. In this review, we will discuss current evidence linking hemodynamics to hemorrhagic transformation after mechanical thrombectomy. In addition, we will review the clinical relevance of cerebral autoregulation in stroke, highlighting recent studies that have harnessed autoregulatory physiology to define and trend individualized limits of autoregulation. This review will go on to emphasize the translatability of this approach to stroke management. Finally, we will discuss novel statistical approaches like trajectory analysis to post-thrombectomy hemodynamics.
出血性转化仍然是治疗大血管闭塞性缺血性卒中的再灌注治疗中一种潜在的灾难性并发症。观察性研究发现，血压升高以及血压变异性高的患者发生出血性转化的风险增加，这表明血流动力学与出血性转化之间存在联系。目前社会认可的指南建议，无论采用溶栓治疗还是血管内介入治疗，都应将血压维持在180/105 mmHg的固定阈值以下。然而，鉴于机械取栓术的再通率很高，尚不清楚血栓切除术前时代的相同血流动力学目标是否适用。此外，可能需要考虑个体患者因素，如再灌注程度、梗死大小和侧支循环状态。在这篇综述中，我们将讨论目前将血流动力学与机械取栓术后出血性转化联系起来的证据。此外，我们将回顾脑自动调节在卒中中的临床相关性，重点介绍最近利用自动调节生理学来定义和追踪个体自动调节极限的研究。这篇综述将继续强调这种方法在卒中管理中的可转化性。最后，我们将讨论血栓切除术后血流动力学的轨迹分析等新的统计方法。
