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Original research
Association between intraprocedural drops in blood pressure and infarct growth rate patterns after acute large-vessel occlusions
  1. Milagros Galecio-Castillo1,
  2. Darko Quispe-Orozco1,
  3. Mudassir Farooqui1,
  4. Andres Dajles2,
  5. Juan Vivanco-Suarez1,
  6. Aaron Rodriguez-Calienes1,
  7. Ayush Prasad3,
  8. Liza Begunova3,
  9. Nils H Petersen3,
  10. Santiago Ortega-Gutierrez1,4
  1. 1Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  2. 2Biostatistics, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  3. 3Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
  4. 4Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  1. Correspondence to Dr Santiago Ortega-Gutierrez, Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; santy-ortega{at}


Background Infarct growth rate (IGR) differs among patients with acute ischemic stroke due to large vessel occlusion (LVO-AIS), and this variability has critical clinical repercussions. We explored IGR patterns and their association with blood pressure during endovascular therapy (EVT).

Methods This is a two-center cohort observational study that included consecutive anterior circulation LVO-AIS patients who underwent EVT and achieved modified Thrombolysis in Cerebral Infarction (mTICI) 2 c-3. Initial and final infarct volumes (FIV) were defined using admission computed tomography perfusion (CTP) defined as relative cerebral blood flow (rCBF) <30%, and diffusion-weighted imaging-magnetic resonance imaging (DWI-MRI) at 24 hours post-EVT. We categorized IGR patterns as exponential (ExpIGR) and Non-exponential (NonExp) based on their growth curves. We then dichotomized ExpIGR clinical significance based on the association of infarct growth with 90-day Modified Rankin Score (mRS) as ExpIGR-A (>13 mL) and ExpIGR-B (<13 mL). Intraprocedural blood pressure (BP) drops were calculated as the difference between median arterial pressure (MAP) at admission and the lowest intraprocedural MAP reading before recanalization, and the area between admission MAP threshold and all lower measurements of intraprocedural MAP. Logistic and linear regression were used to investigate associations between variables of interest.

Results Of 159 modified Thrombolysis in Cerebral Infarction (mTICI) 2 c-3 patients, we found that 36% demonstrated ExpIGR-A, 31% ExpIGR-B, and 32.7% NonExp patterns. The Exp-A and Exp-B groups differed significantly in National Institutes of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early CT Score (ASPECTS), glucose, and FIV. The Exp-A and NonExp groups differed in rCBF <30% vol, and time of stroke onset (SO) to admission CTP; and the Exp-B and NonExp groups in NIHSS, rCBF <30%, Tmax <6 s volume, collateral flow measured by hypoperfusion intensity ratio (HIR), and FIV. Hypotensive MAP area (HMA) was independently associated with an ExpIGR-A pattern. Infarct volume increased by 1 mL per 100 units of hypotensive area and 4.2 mL per 0.1 units of HIR, with a significant interaction between both variables.

Conclusion After an LVO-AIS, the IGR can be differentiated into two distinct exponential and non-exponential patterns. A subgroup of patients with the exponential pattern experienced clinically meaningful infarct growth rates between CTP acquisition and reperfusion and seem to be highly vulnerable to episodes of sustained intraprocedural BP drops during EVT.

  • Stroke
  • Thrombectomy
  • Blood Pressure
  • CT perfusion
  • MR perfusion

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request to the corresponding author.

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Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request to the corresponding author.

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  • Twitter @mili_galecio, @jsvivanco1, @AaronCalienes, @CerebrovascLab

  • MG-C and DQ-O contributed equally.

  • NHP and SO-G contributed equally.

  • Contributors SOG and NP designed the study and revised the manuscript, and are responsible for the overall content as the guarantors. DQO, MGC, AP, LB, MF, ARC, and JVS collected the data. SOG, NP, DQP, MGC, and AD wrote the statistical analysis plan. DQP, MGC, and AD cleaned and analyzed the data. DQO and MGC drafted and revised the manuscript. All the authors approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests NP reports research support from the NIH/NINDS (K23NS110980) and Liminal Sciences. SOG reports research support from the NIH-NINDS (R01NS127114-01), Stryker, Medtronic, Microvention, Methinks, IschemiaView,, and Siemens; and consulting fees from Medtronic and Stryker Neurovascular. The other authors do not report conflict of interests.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.