Acute Hypertensive R Acute Hypertensive R e Response in Stroke: e - PowerPoint PPT Presentation

Acute Hypertensive R Acute Hypertensive R e Response in Stroke: e Response in Stroke: Pathophysiology a Pathophysiology a y and Management y and Management Adnan I. Q Adnan I. Q Qureshi MD Qureshi MD Professor, Neurology, Neur Professor, Neurology, Neur eurosurgery, and Radiology eurosurgery, and Radiology President, International Societ President, International Societ President, International Societ President, International Societ iety of Interventional Neurology iety of Interventional Neurology iety of Interventional Neurology iety of Interventional Neurology For the ATACH I For the ATACH I H II Investigators H II Investigators Zeenat Qureshi Stro Zeenat Qureshi Stro troke Research Center troke Research Center University of Minneso University of Minneso sota, Minneapolis, MN sota, Minneapolis, MN

Initial Systolic Blood Pressure Initial Systolic Blood Pressure ure in Patients Presenting to ure in Patients Presenting to the Emergency Room the Emergency Room m with Stroke in US m with Stroke in US (National Hospital Ambulatory (National Hospital Ambulatory ry Medical Care Survey 2003) ry Medical Care Survey 2003) >220 mm Hg 100% 1858219 mm Hg 1408184 mm Hg ients (%) 80% <140 mm Hg 60% 60% Proportion of patien 40% 20% 0% All IS ICH IC SAH stroke Adapted from: Qureshi AI, et al. A l. Am J Emerg Med 2007;25(1):32#8. .

Acute Hyperten Acute Hyperten tensive Response tensive Response • Stroke specific • Stroke specific • Transient • Transient • Prognostic significanc • Prognostic significanc • Prognostic significanc • Prognostic significanc ance ance ance ance (Qureshi AI: Circulation 200 008 Jul 8;118(2): 176#87 )

Acute hyp Acute hyp ypertensive response: ypertensive response: Stroke s Stroke s e specific disruption of e specific disruption of autonomic activity aut autonomic activity aut Disrupt uption: structural and/o d/or functional Adaptation: functional Parasym ympathetic acti ctivity BP Sympa pathetic act ctivity (Qureshi AI: Circulation 2008 Jul ul 8;118(2):176887)

Treatment of acut Treatment of acut cute hypertensive cute hypertensive response in isch response in isch response in isch response in isch schemic stroke schemic stroke schemic stroke schemic stroke (Qureshi AI: Circula culation 2008 Jul 8;118(2):176887)

Reduction in cer Reduction in cer erebral blood flow erebral blood flow SPECT SPECT CT scan CT scan

Severe hypoperfus Severe hypoperfus fusion (core)8mild to fusion (core)8mild to moderate hypoper moderate hypoper erfusion (penumbra) erfusion (penumbra) alive but alive but but at risk but at risk

Cerebral blood flo Cerebral blood flo flow and cell death flow and cell death Perfusion8Diffu Perfusion8Diffu ffusion mismatch ffusion mismatch Diffusion8weighted MRI Perfusion8weighted MRI

Hypoperfused but a Hypoperfused but a t alive888potentially t alive888potentially salvageable8 salvageable8 888Penumbra 888Penumbra Diffusion8weighted MRI Perfusion8weighted MRI

Rapid collateral form Rapid collateral form ormation during acute ormation during acute intracranial occlusio intracranial occlusio sion888residual rCBF sion888residual rCBF (Qureshi AI: J Vasc Interven (Qureshi AI: J Vasc Interven ent Neurol 2008; 1(3):70872). ent Neurol 2008; 1(3):70872). Balloon inflation ����������� ������������ ���������� ���������� ���������� ����������� ��������� ��

Hypoperfused but alive— Hypoperfused but alive— —vulnerability to systemic —vulnerability to systemic BP change888impaired au BP change888impaired au autoregulation—collaterals autoregulation—collaterals are BP de are BP de dependant dependant SBP=160 mm Hg SBP=100 mm mm Hg

Current guidelines are Current guidelines are re based on the policy re based on the policy of avoiding further of avoiding further of avoiding further of avoiding further her ischemic injury her ischemic injury her ischemic injury her ischemic injury

Intravenous Nim Intravenous Nim Nimodipine West Nimodipine West European St European St Stroke Trial Stroke Trial (Ahmed et al. Cerebrovasc (Ahmed et al. Cerebrovasc sc Diseases 2003;15:235#43) sc Diseases 2003;15:235#43) Total anterior circulation Partial anterior circulation infarction infarction (n=106) (n=106) (n=62) (n=62) Within 24 24 hours IV nimodipine IV nimodipine Placebo Placebo 1 or 2 mg/h 1 or 2 mg/h Diastolic BP reduction No difference in associated with neurological outcome deterioration and outcome

BP reduction harmful? Courtesy of David S. Liebeskind MD, BP reduction UCLA Stroke no effect? Center, LA

Acute hypertensiv Acute hypertensiv sive response should sive response should not be treated in not be treated in in ischemic stroke in ischemic stroke Qureshi AI: Circulation 2 Qureshi AI: Circulation 2 n 2008 Jul 8;118(2):176#87 n 2008 Jul 8;118(2):176#87 Benefit of acute blood pressure reduction unclear A subgroup of patients may deteriorate

American Heart As American Heart As Association Guidelines Association Guidelines 2007 u 2007 u updates updates Pending more data, emerg Pending more data, emerg rgency administration of rgency administration of antihypertensive agents s antihypertensive agents s s should be withheld unless s should be withheld unless the diastolic blood pressu the diastolic blood pressu sure is >120 mm Hg or unless sure is >120 mm Hg or unless the systolic blood pressur the systolic blood pressur sure is >220 mm Hg. sure is >220 mm Hg. The panel remains concern The panel remains concern erned by the evidence that erned by the evidence that aggressive lowering of blo aggressive lowering of blo blood pressure among blood pressure among patients may cause neurol patients may cause neurol rological worsening, and the rological worsening, and the goal is to avoid overtreati goal is to avoid overtreati ating patients with stroke ating patients with stroke until definitive data are a until definitive data are a available. available. American S n Stroke Association Stroke Council. Str Stroke. 38(5):1655#711, 2007 May.

Treatment of acu Treatment of acu acute hypertensive acute hypertensive response in pat response in pat response in pat response in pat atients receiving atients receiving atients receiving atients receiving thromb thromb mbolysis mbolysis (Qureshi AI: Circulat ulation 2008 Jul 8;118(2):176887)

Acute hypertensive re Acute hypertensive re response may increase response may increase the risk of post8throm the risk of post8throm rombolysis intracerebral rombolysis intracerebral hemorr hemorr orrhage orrhage Reperfus Reperfus rfusion rfusion Impaired Impaired autoregulation +coagulo ulopathy +SBP (Qureshi AI: Circula ulation 2008 Jul 8;118(2):176887)

SBP and post8th thrombolytic ICH Studies Patients wit ith Intracranial Predictor acute ischem emic hemorrhage stroke rate ECASS II 793 60 (8%) Baseline SBP (Stroke. 2001; (Stroke. 2001; 32(2):438#41) 32(2):438#41) 1205 158 (13%) Multicenter rt8PA Pre8 stroke survey treatment SBP (Circulation 2002;105:1679#1685) EPITHET 97 15 (15%) Weighted SBP 1824 h ( Stroke. 2010; 41(1):72#7)

American Heart Ass American Heart Ass ssociation Guidelines8 ssociation Guidelines8 Thromb Thromb mbolysis mbolysis • Systolic blood pressure is • Systolic blood pressure is is <=185 mm Hg and their is <=185 mm Hg and their diastolic blood pressure is diastolic blood pressure is is <=110 mm Hg (Class I, is <=110 mm Hg (Class I, Level of Evidence B) befor Level of Evidence B) befor fore lytic therapy is fore lytic therapy is started. started. • M aintained below 180/105 • M aintained below 180/105 05 mm Hg for at least the 05 mm Hg for at least the first 24 hours after intra first 24 hours after intra ravenous rtPA treatment. ravenous rtPA treatment. • Blood pressure recommend • Blood pressure recommend ndations should be followed ndations should be followed in patients undergoing intr in patients undergoing intr ntra8arterial thrombolysis ntra8arterial thrombolysis (Class I, Level of Evidence (Class I, Level of Evidence nce C). nce C). American S n Stroke Association Stroke Council. St Stroke. 38(5):1655#711, 2007 May.

Post8hoc analysis of Post8hoc analysis of of NINDS rt8PA trial of NINDS rt8PA trial Stroke. 29(8):15 Stroke. 29(8):15 150489, 1998 Aug. 150489, 1998 Aug. Acute ischemic stroke and nd received rt8PA SBP >180 mm Hg (3824 h hours after symptom onset) Antihypertensive No antihypertensive treatment ( N=65) treatment (N=112) Clinical 52% 32% improvement at 24 hours

Post8hoc analysis of Post8hoc analysis of of NINDS rt8PA trial of NINDS rt8PA trial Stroke. 29(8):15 Stroke. 29(8):15 150489, 1998 Aug. 150489, 1998 Aug. Acute ischemic stroke and nd received rt8PA SBP >180 mm Hg (3824 h hours after symptom onset) More severe hypertension More severe hypertension Antihypertensive No antihypertensive More abrupt decline of BP in treatment ( N=65) treatment (N=112) response to antihypertensive medication Clinical 52% 32% improvement at 24 hours