Brian Marcus, MD

Mulder MJHL, Ergezen S, Lingsma HF, Berkhemer OA, Fransen PSS, Beumer D, et al. Baseline Blood Pressure Effect on the Benefit and Safety of Intra-Arterial Treatment in MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands). Stroke. 2017

It is known that extremes in blood pressure lead to worse functional outcomes in stroke patients. This article by Mulder et al. looks to see if similar extremes in blood pressure lead to worse outcomes in patients receiving intra-arterial treatment. They performed a post hoc analysis of the MR CLEAN study in the Netherlands and measured blood pressure at baseline and before intra-arterial treatment and compared this with the patient’s modified Rankin scale at 90 days. In addition to looking at modified Rankin scale, the authors also looked to see how blood pressure prior to therapy was related to imaging findings, changes in the NIHSS, TICI score, and the Barthel index.

At the time of this publication, there had been no studies looking into whether a specific blood pressure is considered a contraindication to receiving intra-arterial therapy or whether a certain blood pressure should be treated prior to receiving an intervention. In their analysis, the authors found no interaction between systolic blood pressure and the effect of intra-arterial therapy on functional outcomes. Furthermore, there was no interaction between blood pressure and intra-arterial therapy with regards to radiological outcomes.

It is important to note that no randomized trials of lowering blood pressure prior to intra-arterial treatment have been done yet, but clearly they are warranted in the future. It is also important to note that most of the patients in this study had a systolic blood pressure ranging from 105 to 200 mmHg. Interestingly, the authors found no association between blood pressure and functional outcome or occurrence of symptomatic intracerebral hemorrhage was not affected by intravenous tPA therapy. There is clearly a need to study more specific guidelines for blood pressure goals before, during, and after intra-arterial therapy, but for now, the authors show there is no evidence for a blood pressure threshold in intra-arterial therapy, at least within a range of 105 to 200 mmHg.