The Association of Blood Pressure and Collateral Circulation in Hyperacute Ischemic Stroke Patients Treated with Intravenous ThrombolysisRusanen H.a · Saarinen J.T.b · Sillanpää N.c
aDepartment of Neurology, Oulu University Hospital, Oulu, bDepartment of Neurology, University of Tampere, Vaasa Central Hospital, Vaasa and cMedical Imaging Center, Tampere University Hospital, Tampere, Finland
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Background: The integrity of collateral circulation is a major prognostic factor in ischemic stroke. Patients with good collateral status have larger penumbra and respond better to intravenous thrombolytic therapy. High systolic blood pressure is linked with worse clinical outcome in patients with acute ischemic stroke treated with intravenous thrombolytic therapy. We studied the effect of different blood pressure parameters on leptomeningeal collateral circulation in patients treated with intravenous thrombolytic therapy (<3 h) in a retrospective cohort. Methods: Anterior circulation thrombus was detected with computed tomography angiography and blood pressure was measured prior to intravenous thrombolytic therapy in 104 patients. Baseline clinical and imaging information were collected. Group comparisons were performed; Collateral Score (CS) was assessed and entered into logistic regression analysis. Results: Fifty-eight patients out of 104 displayed good collateral filling (CS ≥2). Poor CS was associated with more severe strokes according to National Institutes of Health Stroke Scale (NIHSS) at arrival (16 vs. 11, p = 0.005) and at 24 h (15 vs. 3, p < 0.001) after the treatment. Good CS was associated with higher systolic blood pressure (p = 0.03), but not with diastolic blood pressure (p = 0.26), pulse pressure (p = 0.20) or mean arterial pressure (p = 0.07). Good CS was associated with better Alberta Stroke Program Early CT Score (ASPECTS) in 24 h follow-up imaging (p < 0.001) and favorable clinical outcome at three months (mRS ≤2, p < 0.001). Median CS was the highest (CS = 3) when systolic blood pressure was between 170 and 190 mm Hg (p = 0.03). There was no significant difference in the number of patients with good (n = 11) and poor (n = 12) CS who received intravenous antihypertensive medication (p = 0.39) before or during the thrombolytic therapy. In multivariate analysis age (p = 0.02, OR 0.957 per year, 95% CI 0.92-0.99), time from the onset of symptoms to treatment (p = 0.005, OR 1.03 per minute, 95% CI 1.01-1.05), distal clot location (p = 0.02, OR 3.52, 95% CI 1.19-10.35) and systolic blood pressure (p = 0.04, OR 1.03 per unit mm Hg, 95% CI 1.00-1.05) predicted good CS. Higher systolic blood pressure (p = 0.049, OR 0.96 per unit mm Hg, 95% CI 0.93-1.00) and pulse pressure (p = 0.005, OR 0.94 per unit mm Hg, 95% CI 0.90-0.98) predicted unfavorable clinical outcome at three months in multivariate analysis. Conclusion: Moderately elevated systolic blood pressure is associated with good collateral circulation in patients treated with intravenous thrombolytic therapy. However, there is an inverse association of systolic blood pressure with the three-month clinical outcome. Diastolic blood pressure, mean arterial pressure and pulse pressure are not statistically and significantly associated with collateral status.
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- Shuaib A, Butcher K, Mohammad AA, Saqqur M, Liebeskind DS: Collateral blood vessels in acute ischaemic stroke: a potential therapeutic target. Lancet Neurol 2011;10:909-921.
- Miteff F, Levi CR, Bateman GA, Spratt N, McElduff P, Parsons MW: The independent predictive utility of computed tomography angiographic collateral status in acute ischaemic stroke. Brain 2009;132:2231-2238.
- Calleja AI, Cortijo E, Garcia-Bermejo P, Gomez RD, Perez-Fernandez S, Del Monte JM, Munoz MF, Fernandez-Herranz R, Arenillas JF: Collateral circulation on perfusion-computed tomography-source images predicts the response to stroke intravenous thrombolysis. Eur J Neurol 2013;20:795-802.
- Kucinski T, Koch C, Eckert B, Becker V, Kromer H, Heesen C, Grzyska U, Freitag HJ, Rother J, Zeumer H: Collateral circulation is an independent radiological predictor of outcome after thrombolysis in acute ischaemic stroke. Neuroradiology 2003;45:11-18.
- Christoforidis GA, Mohammad Y, Kehagias D, Avutu B, Slivka AP: Angiographic assessment of pial collaterals as a prognostic indicator following intra-arterial thrombolysis for acute ischemic stroke. AJNR Am J Neuroradiol 2005;26:1789-1797.
- Lima FO, Furie KL, Silva GS, Lev MH, Camargo EC, Singhal AB, Harris GJ, Halpern EF, Koroshetz WJ, Smith WS, Yoo AJ, Nogueira RG: The pattern of leptomeningeal collaterals on CT angiography is a strong predictor of long-term functional outcome in stroke patients with large vessel intracranial occlusion. Stroke 2010;41:2316-2322.
- Tan IY, Demchuk AM, Hopyan J, Zhang L, Gladstone D, Wong K, Martin M, Symons SP, Fox AJ, Aviv RI: CT angiography clot burden score and collateral score: correlation with clinical and radiologic outcomes in acute middle cerebral artery infarct. AJNR Am J Neuroradiol 2009;30:525-531.
- Liebeskind DS, Tomsick TA, Foster LD, Yeatts SD, Carrozzella J, Demchuk AM, Jovin TG, Khatri P, von Kummer R, Sugg RM, Zaidat OO, Hussain SI, Goyal M, Menon BK, Al Ali F, Yan B, Palesch YY, Broderick JP; IMS III Investigators: Collaterals at angiography and outcomes in the Interventional Management of Stroke (IMS) III trial. Stroke 2014;45:759-764.
- Maas MB, Lev MH, Ay H, Singhal AB, Greer DM, Smith WS, Harris GJ, Halpern E, Kemmling A, Koroshetz WJ, Furie KL: Collateral vessels on CT angiography predict outcome in acute ischemic stroke. Stroke 2009;40:3001-3005.
- Souza LC, Yoo AJ, Chaudhry ZA, Payabvash S, Kemmling A, Schaefer PW, Hirsch JA, Furie KL, Gonzalez RG, Nogueira RG, Lev MH: Malignant CTA collateral profile is highly specific for large admission DWI infarct core and poor outcome in acute stroke. AJNR Am J Neuroradiol 2012,33:1331-1336.
- Bang OY, Saver JL, Kim SJ, Kim GM, Chung CS, Ovbiagele B, Lee KH, Liebeskind DS: Collateral flow predicts response to endovascular therapy for acute ischemic stroke. Stroke 2011;42:693-699.
- Britton M, Carlsson A, de Faire U: Blood pressure course in patients with acute stroke and matched controls. Stroke 1986;17:861-864.
- Ahmed N, Wahlgren N, Brainin M, Castillo J, Ford GA, Kaste M, Lees KR, Toni D; SITS Investigators: Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Stroke 2009;40:2442-2449.
- Yong M, Kaste M: Association of characteristics of blood pressure profiles and stroke outcomes in the ECASS-II trial. Stroke 2008;39:366-372.
- Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA; Group ISTC: Blood pressure and clinical outcomes in the International Stroke Trial. Stroke 2002;33:1315-1320.
- Tsivgoulis G, Saqqur M, Sharma VK, Lao AY, Hill MD, Alexandrov AV; CLOTBUST Investigators: Association of pretreatment blood pressure with tissue plasminogen activator-induced arterial recanalization in acute ischemic stroke. Stroke 2007;38:961-966.
- Mattle HP, Kappeler L, Arnold M, Fischer U, Nedeltchev K, Remonda L, Jakob SM, Schroth G: Blood pressure and vessel recanalization in the first hours after ischemic stroke. Stroke 2005;36:264-268.
- Saarinen JT, Rusanen H, Sillanpää N: Collateral score complements clot location in predicting the outcome of intravenous thrombolysis. AJNR Am J Neuroradiol 2014;35:1892-1896.
- Adams HP Jr, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Kwiatkowski T, Lyden PD, Marler JR, Torner J, Feinberg W, Mayberg M, Thies W: Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 1996;94:1167-1174.
- Sillanpää N, Saarinen JT, Rusanen H, Hakomäki J, Lahteela A, Numminen H, Elovaara I, Dastidar P, Soimakallio S: CT perfusion ASPECTS in the evaluation of acute ischemic stroke: thrombolytic therapy perspective. Cerebrovasc Dis Extra 2011;1:6-16.
- Saarinen JT, Sillanpää N, Rusanen H, Hakomaki J, Huhtala H, Lahteela A, Soimakallio S, Elovaara I, Dastidar P: The mid-M1 segment of the middle cerebral artery is a cutoff clot location for good outcome in intravenous thrombolysis. Eur J Neurol 2012;19:1121-1127.
- Lau AY, Wong EH, Wong A, Mok VC, Leung TW, Wong KS: Significance of good collateral compensation in symptomatic intracranial atherosclerosis. Cerebrovasc Dis 2012;33:517-524.
- Wahlgren N, Ahmed N, Eriksson N, Aichner F, Bluhmki E, Davalos A, Erila T, Ford GA, Grond M, Hacke W, Hennerici MG, Kaste M, Kohrmann M, Larrue V, Lees KR, Machnig T, Roine RO, Toni D, Vanhooren G: Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled trials: Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy (SITS-MOST). Stroke 2008;39:3316-3322.
- Shin HK, Nishimura M, Jones PB, Ay H, Boas DA, Moskowitz MA, Ayata C: Mild induced hypertension improves blood flow and oxygen metabolism in transient focal cerebral ischemia. Stroke 2008;39:1548-1555.
- Lin W, Xiong L, Han J, Leung TW, Soo YO, Chen X, Wong KS: External counterpulsation augments blood pressure and cerebral flow velocities in ischemic stroke patients with cerebral intracranial large artery occlusive disease. Stroke 2012;43:3007-3011.
- Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H: Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947.
- Smit EJ, Vonken EJ, van Seeters T, Dankbaar JW, van der Schaaf IC, Kappelle LJ, van Ginneken B, Velthuis BK, Prokop M: Timing-invariant imaging of collateral vessels in acute ischemic stroke. Stroke 2013;44:2194-2199.
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