Association of blood pressure and outcomes differs upon cerebral perfusion post-thrombectomy in patients with acute ischemic stroke.

BACKGROUND: The relationship between post-endovascular thrombectomy (EVT) blood pressure (BP) and outcomes in patients with acute ischemic stroke (AIS) remains contentious. We aimed to explore whether this association differs with different cerebral perfusion statuses post-EVT. METHODS: In a multicenter observational study of patients with AIS with large vessel occlusion who underwent EVT, we enrolled those who accepted CT perfusion (CTP) imaging within 24 hours post-EVT. We recorded post-EVT systolic (SBP) and diastolic BP. Patients were stratified into favorable perfusion and unfavorable perfusion groups based on the hypoperfusion intensity ratio (HIR) on CTP. The primary outcome was good functional outcome (90-day modified Rankin Scale score of ≤3). Secondary outcomes included early neurological deterioration, infarct size growth, and symptomatic intracranial hemorrhage. RESULTS: Of the 415 patients studied (mean age 62 years, 75% male), 233 (56%) achieved good functional outcomes. Logistic regression showed that post-EVT HIR and 24-hour mean SBP were significantly associated with functional outcomes. Among the 326 (79%) patients with favorable perfusion, SBP <140 mmHg was associated with a higher percentage of good functional outcomes compared with SBP ≥140 mmHg (68% vs 52%; aOR 1.70 (95% CI 1.00 to 2.89), P=0.04). However, no significant difference was observed between SBP and functional outcomes in the unfavorable perfusion group. There was also no discernible difference between SBP and secondary outcomes across the different perfusion groups. CONCLUSIONS: In patients with favorable perfusion post-EVT, SBP <140 mmHg was associated with good functional outcomes, which underscores the need for further investigations with larger sample sizes or a more individualized BP management strategy. CLINICAL TRIAL REGISTRATION: ChiCTR1900022154.

Deviation From Personalized Blood Pressure Targets Correlates With Worse Outcome After Successful Recanalization.

BACKGROUND: Personalized blood pressure (BP) management for patients with acute ischemic stroke after successful endovascular thrombectomy lacks evidence. We aimed to investigate whether the deviation of BP from cerebral autoregulation limits is associated with worse outcomes. METHODS AND RESULTS: We determined autoregulation by measuring mean velocity index and calculated the percentage of time and the burden (defined as the time-BP area) with BP outside the autoregulatory limits of each subject within 48 hours after endovascular thrombectomy. In total, 91 patients with large vessel occlusion stroke who had achieved successful recanalization were prospectively enrolled between May 2020 and February 2022. The burden with BP outside the autoregulatory limits was associated with poor outcome (modified Rankin Scale score 3-6) at 90 days (adjusted odds ratio, 1.28 [95% CI, 1.03-1.59]). The percentage of time with BP out of the autoregulatory limits was correlated with early neurological deterioration (National Institute of Health Stroke Scale scores increased ≥2 at 7 days) (adjusted odds ratio, 1.38 [95% CI, 1.04-1.83]). The burden of BP that decreased below the autoregulatory lower limit was associated with significant infarct growth (volume of infarct growth >11.6 mL) at 7 days (adjusted odds ratio, 1.21 [95% CI, 1.01-1.44]). The percentage of time that BP exceeded the autoregulatory upper limit was associated with symptomatic intracranial hemorrhage within 48 hours (adjusted odds ratio, 1.55 [95% CI, 1.02-2.34]). CONCLUSIONS: Both the percentage of time and the burden of BP that deviates from the autoregulation-preserved range are associated with unfavorable clinical outcomes. This study highlights the potential benefits of autoregulation-guided BP management strategy after successful recanalization.

Development, Evaluation, and impLemenTation for guideline adaptation: a quality improvement protocol for the DELTA study in global health practice.

BACKGROUND: Guideline adaptation is an emerging field to provide more appropriate recommendations for local clinical practice quality and to promote global health equity. However, its utilization status, adaptation procedures, and related materials remain to be studied. METHODS: This study developed a quality improvement protocol for a study as the Development, Evaluation, and impLemenTation for guideline Adaptation (DELTA) study. Current adapted clinical practice guidelines (CPGs) will be systematically searched. Their characteristics, utilization status, and adaptation procedures will be extracted, compared, and analyzed. Whether these adapted CPGs rigorously followed the instruments and steps of adaptation frameworks will also be appraised. In addition, the advantages and limitations of current adaptation methods and their suitable application situations will be analyzed. In addition, future perspectives as DELTA series and DELTA system, aiming for comprehensively evaluating current needs for guideline adaptation and developing a unified framework and related materials were proposed to improve the acceptability, applicability, and implementation of guideline adaptation in clinical practice. The DELTA series are divided into four phases: phase I in analyzing status, characteristics, and procedures and completeness of adapted CPGs; phase II in analyzing differences, heterogeneity, and implementation between adapted and original CPGs; and phase III in collecting, analyzing, and comparing all available adaptation materials. With these research bases, an international working group will be established in phase IV and will develop unified guideline adaptation materials after Delphi consensus, including adaptation frameworks, appraisal tools and checklists, registries, and databases. DISCUSSION: Guideline adaptation has been advanced as an efficient way to guide local clinical practice. However, it still faces several major challenges. The proposed DELTA study, series, and system will further contribute to this emerging topic. TRIAL REGISTRATION:  This study has been registered by the PROSPERO international database. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=400170 .