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Lookup NU author(s): Professor Phil White
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© 2023 Elsevier LtdBackground: Current guidelines for ischaemic stroke treatment recommend a strict, but arbitrary, upper threshold of 185/110 mm Hg for blood pressure before endovascular thrombectomy. Nevertheless, whether admission blood pressure influences the effect of endovascular thrombectomy on outcome remains unknown. Our aim was to study the influence of admission systolic blood pressure (SBP) on functional outcome and on the effect of endovascular thrombectomy. Methods: We used individual patient data from seven randomised controlled trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, PISTE, and THRACE) that randomly assigned patients with anterior circulation ischaemic stroke to endovascular thrombectomy (predominantly using stent retrievers) or standard medical therapy (control) between June 1, 2010, and April 30, 2015. We included all patients for whom SBP data were available at hospital admission. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. We assessed the association of SBP with outcome in both the endovascular thrombectomy group and the control group using multilevel regression analysis and tested for non-linearity and for interaction between SBP and effect of endovascular thrombectomy, taking into account treatment with intravenous thrombolysis. Findings: We included 1753 patients (867 assigned to endovascular thrombectomy, 886 assigned to control) after excluding 11 patients for whom SBP data were missing. We found a non-linear association between SBP and functional outcome with an inflection point at 140 mm Hg (732 [42%] of 1753 patients had SBP <140 mm Hg and 1021 [58%] had SBP ≥140 mm Hg). Among patients with SBP of 140 mm Hg or higher, admission SBP was associated with worse functional outcome (adjusted common odds ratio [acOR] 0·86 per 10 mm Hg SBP increase; 95% CI 0·81–0·91). We found no association between SBP and functional outcome in patients with SBP less than 140 mm Hg (acOR 0·97 per 10 mm Hg SBP decrease, 95% CI 0·88–1·05). There was no significant interaction between SBP and effect of endovascular thrombectomy on functional outcome (p=0·96). Interpretation: In our meta-analysis, high admission SBP was associated with worse functional outcome after stroke, but SBP did not seem to negate the effect of endovascular thrombectomy. This finding suggests that admission SBP should not form the basis for decisions to withhold or delay endovascular thrombectomy for ischaemic stroke, but randomised trials are needed to further investigate this possibility. Funding: Medtronic.
Author(s): Samuels N, van de Graaf RA, Mulder MJHL, Brown S, Roozenbeek B, van Doormaal PJ, Goyal M, Campbell BCV, Muir KW, Agrinier N, Bracard S, White PM, Roman LS, Jovin TG, Hill MD, Mitchell PJ, Demchuk AM, Bonafe A, Devlin TG, van Es ACGM, Lingsma HF, Dippel DWJ, van der Lugt A
Publication type: Article
Publication status: Published
Journal: The Lancet Neurology
Year: 2023
Volume: 22
Issue: 4
Pages: 312-319
Print publication date: 01/04/2023
Online publication date: 15/03/2023
Acceptance date: 20/02/2023
ISSN (print): 1474-4422
ISSN (electronic): 1474-4465
Publisher: Elsevier Ltd
URL: https://doi.org/10.1016/S1474-4422(23)00076-5
DOI: 10.1016/S1474-4422(23)00076-5
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