*These authors are co-first authors.
Interventional Neuroradiology Department (B.M., R.B., S.E., J.-P.D., R.B., M.P., M.M.), Hôpital Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Université Paris-Cité (B.M., J.-P.D., R.B., M.P., M.M.), Paris, France; FHU NeuroVasc (B.M., J.-P.D., R.B., M.P., M.M.), Paris, France; EA4245-Transplantation (B.M., J.-M.H.), Immunology and Inflammation, University of Tours, 37032, Tours, France; Sackler Faculty of Medicine (R.B.), Tel Aviv University, Tel Aviv, Israel; Université de Lorraine (B.G.), CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, F-54000 Nancy, France; Université de Lorraine (B.G.), IADI, INSERM U1254, F-54000 Nancy, France; Department of Neurology (B.L.), Division of Neurology, Stroke Centre, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Stroke Unit (I.S.), CHU Bordeaux, Université de Bordeaux, Bordeaux, France; Université de Lorraine (S.R.), CHRU-Nancy, Department of Neurology, Nancy, France; Univ. Lille, CHU Lille (J.L., M.K.), EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France; Laboratory of Vascular Translational Science (J.-P.D., R.B., M.P., M.M.), INSERM U1148, Paris, France; Nephrology Department, Tours Hospital (, J.-M.H.), Tours, France; and Université de Tours (, J.-M.H.), Tours, France.
Neurology. 2022 Nov 22;99(21):e2385-e2394. doi: 10.1212/WNL.0000000000201173. Epub 2022 Aug 30.
Observational studies described associations between higher systolic blood pressure (SBP) values and intracranial hemorrhages (ICHs) and worse outcomes after successful reperfusion by endovascular therapy (EVT). However, the BP-TARGET trial [BP-Target in Acute Ischemic Stroke to Reduce Hemorrhage after EVT] found that an intensive SBP target did not reduce ICH rates after successful EVT. The presence of contrast enhancement (CE) immediately after reperfusion is also associated with higher odds of ICH and worse outcomes. Our research question was to investigate the effect of 2 SBP strategies after reperfusion on ICH rates and functional outcomes according to the presence of CE in the BP-TARGET trial. We hypothesized that patients with CE could benefit from an intensive SBP control.
We included BP-TARGET patients in whom a brain flat panel was performed immediately after reperfusion. We described CE as present or absent, ICH consisted of any radiographic ICH 24 hours after EVT, and unfavorable outcome consisted of a modified Rankin Scale score between 3 and 6 at 3 months.
Among the 324 patients randomized in BP-TARGET, 164 were included in this analysis, of whom 113 (68.9%) presented CE after reperfusion. The 24-hour mean SBP was significantly lower in the intensive SBP group compared with the standard group (129.7 vs 138.3 mm Hg, < 0.001). Patients with CE and randomized in the intensive and standard SBP group had increased ICH rates: aOR = 11.26, 95% CI 4.59-27.63, and aOR = 4.08, 95% CI 1.75-9.50, respectively. However, the test of heterogeneity did not reach the significant level (aOR = 2.76, 95% CI 0.80 to 9.48, = 0.11). Patients with CE and randomized in the intensive SBP group had also higher odds of unfavorable outcomes (aOR = 2.91, 95% CI 1.24-6.82), but this association was not significant in the standard SBP group (aOR = 1.89, 95% CI 0.85-4.23). No significant heterogeneity was found between the 2 groups (aOR, 1.54, 95% CI 0.48 to 4.97, = 0.47).
Altogether, patients with CE and randomized in the intensive SBP group did not have lower rates of ICH or improved outcomes compared with the standard SBP group, as CE was associated with higher odds of ICH in both groups, without significant heterogeneity.
NCT03160677.
This study provides Class IV evidence that for adults with contrast-enhancing lesions after successful EVT of an AIS, intensive blood pressure management did not significantly increase the risk of ICH.
观察性研究描述了较高的收缩压（SBP）值与血管内治疗（EVT）成功后颅内出血（ICH）和预后较差之间的关联。然而，BP-TARGET 试验[急性缺血性卒中的 BP-TARGET，以降低 EVT 后的出血率]发现，强化 SBP 目标并不能降低 EVT 成功后的 ICH 发生率。再灌注后即刻出现对比增强（CE）也与更高的 ICH 发生率和更差的结局相关。我们的研究问题是调查 BP-TARGET 试验中再灌注后两种 SBP 策略对 ICH 发生率和功能结局的影响，根据 CE 的存在情况。我们假设存在 CE 的患者可以从强化 SBP 控制中获益。
我们纳入了再灌注后立即进行脑部平板检查的 BP-TARGET 患者。我们将 CE 描述为存在或不存在，ICH 定义为 EVT 后 24 小时任何影像学 ICH，不良结局定义为 3 个月时改良 Rankin 量表评分在 3 到 6 之间。
在 BP-TARGET 中随机的 324 名患者中，有 164 名患者纳入了本分析，其中 113 名（68.9%）患者再灌注后出现 CE。强化 SBP 组的 24 小时平均 SBP 明显低于标准 SBP 组（129.7 比 138.3mmHg，<0.001）。CE 且随机分组于强化 SBP 和标准 SBP 组的患者 ICH 发生率增加：比值比（aOR）=11.26，95%置信区间（CI）为 4.59-27.63，和 aOR = 4.08，95% CI 1.75-9.50。然而，异质性检验未达到显著水平（aOR = 2.76，95% CI 0.80-9.48，=0.11）。CE 且随机分组于强化 SBP 组的患者不良结局的可能性也更高（aOR = 2.91，95% CI 1.24-6.82），但在标准 SBP 组中这种关联并不显著（aOR = 1.89，95% CI 0.85-4.23）。两组间未发现显著的异质性（aOR，1.54，95% CI 0.48-4.97，=0.47）。
总的来说，与标准 SBP 组相比，CE 且随机分组于强化 SBP 组的患者 ICH 发生率或结局改善无差异，因为 CE 与两组患者的 ICH 发生率增加相关，且无显著异质性。
NCT03160677。
本研究提供了 IV 级证据，表明对于 EVT 成功后存在对比增强病变的急性缺血性卒中患者，强化血压管理并未显著增加 ICH 风险。
