Abstract
Objective To evaluate the role of blood pressure (BP) as mediator of the effect of conscious sedation (CS) compared to local anesthesia (LA) on functional outcome after endovascular treatment (EVT).
Methods Patients treated in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry centers with CS or LA as preferred anesthetic approach during EVT for ischemic stroke were analyzed. First, we evaluated the effect of CS on area under the threshold (AUT), relative difference between baseline and lowest procedural mean arterial pressure (∆LMAP), and procedural BP trend, compared to LA. Second, we assessed the association between BP and functional outcome (modified Rankin Scale [mRS]) with multivariable regression. Lastly, we evaluated whether BP explained the effect of CS on mRS.
Results In 440 patients with available BP data, patients treated under CS (n = 262) had larger AUTs (median 228 vs 23 mm Hg*min), larger ∆LMAP (median 16% vs 6%), and a more negative BP trend (−0.22 vs −0.08 mm Hg/min) compared to LA (n = 178). Larger ∆LMAP and AUTs were associated with worse mRS (adjusted common odds ratio [acOR] per 10% drop 0.87, 95% confidence interval [CI] 0.78–0.97, and acOR per 300 mm Hg*min 0.89, 95% CI 0.82–0.97). Patients treated under CS had worse mRS compared to LA (acOR 0.59, 95% CI 0.40–0.87) and this association remained when adjusting for ∆LMAP and AUT (acOR 0.62, 95% CI 0.42–0.92).
Conclusions Large BP drops are associated with worse functional outcome. However, BP drops do not explain the worse outcomes in the CS group.
Glossary
- aβ=
- adjusted β;
- acOR=
- adjusted common odds ratio;
- ASPECTS=
- Alberta Stroke Program Early CT Score;
- AUT=
- area under the threshold;
- BP=
- blood pressure;
- CI=
- confidence interval;
- CS=
- conscious sedation;
- eTICI=
- extended thrombolysis in cerebral infarction;
- EVT=
- endovascular treatment;
- GA=
- general anesthesia;
- IQR=
- interquartile range;
- LA=
- local anesthesia;
- LMAP=
- lowest procedural mean arterial pressure;
- MAP=
- mean arterial pressure;
- MR CLEAN=
- Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands;
- mRS=
- modified Rankin Scale;
- NIHSS=
- NIH Stroke Scale;
- RCT=
- randomized controlled trial;
- sICH=
- symptomatic intracranial hemorrhage
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
The Article Processing Charge was funded by the Erasmus University Medical Center.
The MR CLEAN Registry Investigators are listed at links.lww.com/WNL/B252.
- Received April 10, 2020.
- Accepted in final form August 24, 2020.
- Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
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