Aaron Tansy, MD

 

Consensus agreement supports permissive hypertension as a mainstay in the non-thrombolytic treatment of hyperacute/early acute ischemic stroke to compensate for loss of autoregulation and promote cerebral perfusion. Beyond that, what the best practice may be for blood pressure (BP) management in the acute ischemic setting, especially for patients treated with intravenous thrombolysis, has kept the stroke community scratching its collective head for some time.

To that end, Kaoru Endo and colleagues report on early and late clinical outcomes seen across differing BP courses in early acute ischemic stroke treated with thrombolytic therapy. Culled from the SAMURAI rt-PA registry, data for 527 patients were analyzed retrospectively. BP values for each patient were recorded once immediately prior to and 7 times after rt-PA administration over a 24 hour period, and were converted into individual BP statistical profiles (max, min, mean, difference between max and min, standard deviation, and coefficient of variation). Clinical outcomes assessed were symptomatic intracerebral hemorrhage (sICH) within 36 hours (early) and modified Rankin Scale (mRS) score or death at 3 months (late). Associations between BP profiles and outcomes were performed using binomial logistic regression models.

The group’s analysis yielded two major findings: severity of BP elevation and variability both appeared to influence clinical outcomes. On the one hand, patients with sICH tended to have a higher overall BP course during the first 24 hours of ischemic stroke while, on the other, those with a low (0-1) mRS score had a significantly lower one. In addition, both patients with sICH and who died had BP courses of significantly larger variability early after ischemic stroke while those with a low mRS score had ones of significantly lesser variability.

Although the finding that an early elevated BP course is predictive of poor outcomes is not surprising, the study has noteworthy results. For one, the study’s overall findings make it the first to highlight the prognostic potential of monitoring the early BP course in thrombolytic-treated acute ischemic stroke. Additionally, and perhaps more importantly, it is the first to suggest that degree of BP variability no less significantly impacts clinical outcome than degree of BP elevation.

So, while the trial doesn’t provide any definitive answers regarding BP management for thrombolytic-treated acute ischemic stroke, it does open a few new doorways worth exploring that may bring us a few steps closer to some.