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Blood Pressure and Functional Outcome After Stroke Thrombectomy
Study Questions:
Are blood pressure (BP) drops associated with worse short- and long-term functional outcomes in acute stroke patients undergoing mechanical thrombectomy under conscious sedation (CS) or general anesthesia (GA)?
Methods:
This is a post hoc analysis of the single-site SIESTA (Sedation vs Intubation for Endovascular Stroke Treatment) trial, which randomized 150 acute stroke patients undergoing mechanical thrombectomy to CS versus GA, with strict protocols to target a systolic BP (SBP) of 140-160 mm Hg. The SIESTA trial found no significant difference between the CS and GA groups in regard to the primary outcome of early neurologic improvement. In this analysis, subjects’ peri-thrombectomy BPs were recorded and divided into four different procedure stages: upon presentation to the emergency department, pre-recanalization, post-recanalization, and after admission to the neurointensive care unit. Short-term functional outcome was represented by change in National Institutes of Health Stroke Scale (NIHSS) score from admission to 24 hours. Long-term functional outcome was represented by 3-month modified Rankin scale (mRS) score.
Results:
Data from the 73 GA and 77 CS patients enrolled in SIESTA were included in this analysis. No association was observed between early neurologic improvement (change in NIHSS score) and change in SBP, change in diastolic BP (DBP), or change in mean arterial pressure (MAP) from baseline at any procedure stage. These results appeared independent of sedation group (GA vs. CS). Similarly, no association was observed between long-term functional outcome (3-month mRS) and change in SBP, change in DBP, or change in MAP from baseline at any procedure stage. These results also appeared independent of sedation group.
Conclusions:
Peri-thrombectomy BP drops were not associated with changes in short- or long-term functional outcome in the SIESTA trial, regardless of sedation group.
Perspective:
This post hoc analysis suggests that drops in BP do not worsen short- and long-term functional outcomes for patients undergoing mechanical thrombectomy for large vessel ischemic stroke. However, in the original SIESTA trial, SBP was strictly targeted at 140-160 mm Hg, limiting the generalizability of these findings to thrombectomy patients without strict BP targets. Far more clinically meaningful are the results of the original SIESTA trial, which suggested that post-thrombectomy functional outcomes are independent of sedation group if SBP is targeted at 140-160 mm Hg. The SIESTA results were surprising to some who suspected that drops in BP associated with GA would result in worse functional outcomes for thrombectomy patients.
Keywords: Anesthesia, General, Arterial Pressure, Blood Pressure, Brain Ischemia, Conscious Sedation, Emergency Service, Hospital, Intubation, Neurology, Outcome Assessment, Health Care, Secondary Prevention, Stroke, Thrombectomy, Vascular Diseases
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