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Ischemic stroke
Original research
A decrease in blood pressure is associated with unfavorable outcome in patients undergoing thrombectomy under general anesthesia
  1. Kilian M Treurniet1,
  2. Olvert A Berkhemer1,2,3,
  3. Rogier V Immink4,
  4. Hester F Lingsma5,
  5. Vivian M C Ward-van der Stam4,
  6. Markus W Hollmann4,
  7. Jaap Vuyk6,
  8. Wim H van Zwam3,
  9. Aad van der Lugt7,
  10. Robert J van Oostenbrugge8,
  11. Diederik W J Dippel2,
  12. Jonathan M Coutinho9,
  13. Yvo B W E M Roos9,
  14. Henk A Marquering1,10,
  15. Charles B L M Majoie1
  16. for the MR CLEAN investigators
    1. 1Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
    2. 2Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
    3. 3Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
    4. 4Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
    5. 5Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
    6. 6Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
    7. 7Department of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
    8. 8Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
    9. 9Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
    10. 10Department of Biomedical Engineering & Physics, Academic Medical Center, Amsterdam, The Netherlands
    1. Correspondence to Professor Charles B L M Majoie, C1-426, Department of Radiology, Academic Medical Center, PO Box 22660, Amsterdam 1100DD, The Netherlands; c.b.majoie{at}amc.uva.nl

    Abstract

    Background Up to two-thirds of patients are either dependent or dead 3 months after thrombectomy for acute ischemic stroke (AIS). Loss of cerebral autoregulation may render patients with AIS vulnerable to decreases in mean arterial pressure (MAP).

    Objective To determine whether a fall in MAP during intervention under general anesthesia (GA) affects functional outcome.

    Methods This subgroup analysis included patients from the MR CLEAN trial treated with thrombectomy under GA. The investigated variables were the difference between MAP at baseline and average MAP during GA (ΔMAP) as well as the difference between baseline MAP and the lowest MAP during GA (ΔLMAP). Their association with a shift towards better outcome on the modified Rankin Scale (mRS) after 90 days was determined using ordinal logistic regression with adjustment for prognostic baseline variables.

    Results Sixty of the 85 patients treated under GA in MR CLEAN had sufficient anesthetic information available for the analysis. A greater ΔMAP was associated with worse outcome (adjusted common OR (acOR) 0.95 per point mm Hg, 95% CI 0.92 to 0.99). An average MAP during GA 10 mm Hg lower than baseline MAP constituted a 1.67 times lower odds of a shift towards good outcome on the mRS. For ΔLMAP this association was not significant (acOR 0.97 per mm Hg, 95% CI 0.94 to 1.00, p=0.09).

    Conclusions A decrease in MAP during intervention under GA compared with baseline is associated with worse outcome.

    Trial registration number NTR1804; ISRCTN10888758; post-results.

    • Thrombectomy
    • Stroke
    • Blood Pressure

    https://doi.org/10.1136/neurintsurg-2017-012988

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      Footnotes

      • Collaborators Executive committee: Diederik W J Dippel1; Aad van der Lugt2; Charles B L M Majoie3; Yvo B W E M Roos4; Robert J van Oostenbrugge5; Wim H van Zwam6; Olvert A Berkhemer1,3; Puck S S Fransen1,2; Debbie Beumer1,5; Lucie A van den Berg4. Local principal investigators: Wouter J Schonewille7; Jan Albert Vos8; Charles B L M Majoie3; Yvo B W E M Roos4; Paul J Nederkoorn4; Marieke J H Wermer9; Marianne A A van Walderveen10; Robert J van Oostenbrugge5; Wim H van Zwam6; Julie Staals5; Jeannette Hofmeijer11; Jacques A van Oostayen12; Geert J Lycklama à Nijeholt13; Jelis Boiten14; Diederik W J Dippel1; Patrick A Brouwer2; Bart J Emmer2; Sebastiaan F de Bruijn15; Lukas C van Dijk16; L Jaap Kappelle17; Rob H Lo18; Ewoud J van Dijk19; Joost de Vries20; Paul L M de Kort21; Jan S P van den Berg22; Willem Jan J van Rooij22; Boudewijn A A M van Hasselt23; Leo A M Aerden24; René J Dallinga25; Marieke C Visser26; Joseph C J Bot27; Patrick C Vroomen28; Omid Eshghi29; Tobien H C M L Schreuder30; Roel J J Heijboer31; Koos Keizer32; Alexander V Tielbeek33; Heleen M den Hertog34; Dick G Gerrits35; Renske M van den Berg-Vos36; Giorgos B Karas37. Imaging assessment committee: Charles B L M Majoie3 (chair); Wim H van Zwam6; Aad van der Lugt2; Geert J Lycklama à Nijeholt13; Marianne A A van Walderveen10, Joseph C J Bot27; Henk A Marquering38; Ludo F Beenen3; Marieke E S Sprengers3; Sjoerd F M Jenniskens39, René van den Berg3; Olvert A Berkhemer1,3; Albert J Yoo40. Outcome assessment committee: Yvo B W E M Roos4 (chair); Peter J Koudstaal1; Jelis Boiten; Ewoud J. van Dijk19. Adverse event committee: Robert J van Oostenbrugge5 (chair); Marieke J H Wermer9; H Zwenneke Flach23. Trial statisticians: Ewout W Steyerberg41; Hester F Lingsma41. List of affiliations: Department of Neurology1, Radiology2, Public Health41, Erasmus MC University Medical Center, Rotterdam; Department of Radiology3, Neurology4, Biomedical Engineering and Physics38, Academic Medical Center, Amsterdam; Department of Neurology5, Radiology6, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM); Department of Neurology7, Radiology8, Sint Antonius Hospital, Nieuwegein; Department of Neurology9, Radiology10, Medical Statistics and Bioinformatics44, Leiden University Medical Center; Department of Neurology11, Radiology12, Rijnstate Hospital, Arnhem; Department of Radiology13, Neurology14, MC Haaglanden, the Hague; Department of Neurology15, Radiology16, HAGA Hospital, the Hague; Department of Neurology17, Radiology18, University Medical Center Utrecht; Department of Neurology19, Neurosurgery20, Radiology39, Radboud University Medical Center, Nijmegen; Department of Neurology21, Sint Elisabeth Hospital, Tilburg; Department of Neurology22, Radiology23, Isala Klinieken, Zwolle; Department of Neurology24, Radiology25, Reinier de Graaf Gasthuis, Delft; Department of Neurology26, Radiology27, VU Medical Center, Amsterdam; Department of Neurology28, Radiology29, University Medical Center Groningen, the Netherlands; Department of Neurology30, Radiology31, Atrium Medical Center, Heerlen; Department of Neurology32, Radiology33, Catharina Hospital, Eindhoven; Department of Neurology34, Radiology35, Medical Spectrum Twente, Enschede; Department of Neurology36, Radiology37, Sint Lucas Andreas Hospital, Amsterdam; all in the Netherlands; Department of Radiology40, Texas Stroke Institute, Texas, USA.

      • Contributors KMT collected and cleaned data for this study, wrote the statistical analysis plan, analyzed the data, and drafted and revised the paper. He is guarantor. OAB implemented the MR CLEAN trial in the Netherlands, collected and cleaned the data for the trial and this study, and revised the draft paper. RVI, JV, and VMCW-vdS helped with the collection of data for this study and revised the draft paper. MWH and JMC revised the draft paper. HFL helped with the statistical analysis plan and revised the draft paper. RJvO, WHvZ, DWJD, AvdL and YBWEMR designed the MR CLEAN trial, implemented the trial in the Netherlands, oversaw data collection, and revised the draft paper of this study. HAM helped with the statistical analysis plan and drafted and revised the draft paper. CBLMM designed the MR CLEAN trial, implemented the trial in the Netherlands, oversaw data collection, planned this study, and drafted and revised the paper. The MR CLEAN investigators (listed in the appendix) collected the data for the MR CLEAN trial.

      • Funding The MR CLEAN trial was partly funded by the Dutch Heart Foundation grant number: 2008T30 and by unrestricted grants from AngioCare BV, Medtronic/Covidien/EV3, MEDAC Gmbh/LAMEPRO, Penumbra Inc, Stryker, and Top Medical/Concentric. The sponsors of the MR CLEAN trial were not involved in the design of the study, writing of the protocol, study conduct, or preparation or review of the article. The members of the executive committee and local investigators of the participating centers alone performed these tasks.

      • Competing interests Erasmus MC received funds from Stryker and Bracco Imaging for consultations by DWJD and AvdL. AMC received funds from Stryker for consultations by CBLMM, YBWEMR, and OAB. MUMC received funds from Stryker and Codman for consultations by WHvZ.

      • HAM is co-founder and shareholder of Nico-Lab.

      • Provenance and peer review Not commissioned; externally peer reviewed.