Increased blood pressure variability during general anaesthesia is associated with worse outcomes after mechanical thrombectomy: a prospective observational cohort study

Abstract

Objectives: Optimal periprocedural blood pressure (BP) management during mechanical thrombectomy (MT) for acute ischaemic stroke is still controversial. The aim of this study was to investigate the association between intraprocedural BP variability (BPV) and outcomes in patients with large vessel occlusion (LVO) following MT with general anaesthesia.

Design: A prospective observational cohort study.

Setting: This study was conducted in a single tertiary hospital of Hangzhou in Zhejiang province.

Participants: A total of 141 patients with LVO treated with MT were finally included between January 2018 and September 2020.

Main outcome measures: Intraprocedural BP was recorded every 5 min throughout the procedure. BPV was measured as SD, coefficient of variation (CV), max-min (RANGE) and successive variation. Haemorrhagic transformation was assessed on 24-hour CT images according to European Cooperative Acute Stroke Study III trial. Poor functional outcome was defined as 90-day modified Rankin Scale score 3-6. Binary logistic regression analysis was used to investigate the association of BPV parameters with the incidence of parenchymal haemorrhage (PH) and poor functional outcome.

Results: After controlling for age, female, history of smoking, hypertension and atrial fibrillation, baseline National Institutes of Health Stroke Scale, baseline systolic BP (SBP), baseline Alberta Stroke Program Early CT Score, bridging thrombolysis and times of retrieval attempts, the results demonstrated that intraprocedural SBP_RANGE (OR 1.029; 95% CI 1.003 to 1.055; p=0.027), SBP_SD (OR 1.135; 95% CI 1.023 to 1.259; p=0.017) and SBP_CV (OR 1.189; 95% CI 1.053 to 1.342; p=0.005) were independently associated with poor functional outcome. However, the independent association between intraprocedural BPV and PH at 24 hours has not been established in this study.

Conclusions: Increased intraprocedural BPV was more likely to have poor functional outcome in patients with LVO following MT with general anaesthesia. This finding indicates that special precautions should be taken to minimise BP fluctuation during procedure.

Keywords: adult neurology; neurosurgery; stroke.

Figure 1

Patients flow chart. LVO, large vessel occlusion; MT, mechanical thrombectomy; TICI, Thrombolysis in Cerebral Infarction.

Figure 2

Spline plots of different parameters of intraprocedural BP variability, measured as SBP_RANGE/SBP_SD, and adjusted OR. The area between the two dashed lines indicates the 95% CI. BP, blood pressure; SBP, systolic BP.

Figure 3

ROC curves of intraprocedural SBP_RANGE and SBP_SD to predict poor functional outcome. ROC, receiver operating characteristics; SBP, systolic blood pressure.