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iNature
Mechanical thrombectomy is the first-line treatment for large-vessel occlusive acute ischemic stroke, and vascular recanalization through stent thrombectomy and thrombus extraction can significantly improve the clinical prognosis of patients and save ischemic semi-dark zone brain tissue
.
However, even with the current high rate of imaging recanalization, half of patients are left with severe disability or death, so blood pressure management is one of
the important tools for clinicians to try to improve clinical outcomes through other treatments.
However, the optimal systolic blood pressure after intravascular thrombectomy in acute ischaemic stroke is uncertain
.
On October 27, 2022, Professor Liu Jianmin's team at Naval Military Medical University and Craig Anderson team at The George Institute for Global Health published an online publication titled " Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial The study is the world's largest clinical randomized controlled study on blood pressure management after endovascular treatment of acute ischemic stroke, and the study found that the clinical function prognosis of patients in the intensive antihypertensive group (<120mmHg) was worse
than that in the standard blood pressure group (140~180mmHg).
This finding provides high-level evidence-based evidence
for blood pressure management after mechanical embolectomy.
In addition, on May 21, 2020, Liu Jianmin's team from the Naval Medical University published an online publication entitled "Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke" in the internationally renowned medical journal NEJM (IF=176).
The study is a prospective, multicenter, randomized controlled study, covering 41 academic tertiary hospitals across the country, screening a total of 1586 patients with acute large-vessel occlusive ischemic stroke with onset of anterior circulation within 4.
5 hours, and finally 656 cases were included in the study, randomly divided into direct embolectomy group (simple endovascular embolectomy, 327 cases) and combination treatment group (intravenous thrombolysis with alteplase before thrombectomy, alteplase at 0.
9) according to the ratio of 1:1 mg/kg dose, 329 cases).
The study found that intravascular thrombectomy alone was not inferior to combination intravenous alteplase and endovascular thrombectomy (adjusted common odds ratio, 1.
07; 95% confidence interval, 0.
81 to 1.
40; non-inferiority P = 0.
04).
However, the direct embolectomy group had lower pre-embolectomy reperfusion (2.
4 versus 7.
0 percent, OR=0.
33) and overall successful reperfusion (79.
4 versus 84.
5 percent, OR=0.
7) than in the combination group
.
The 90-day mortality rate was 17.
7% in the embolectomy group alone and 18.
8%
in the combination therapy group.
In conclusion, for patients with acute anterior circulating macrovascular occlusive ischemic stroke within 4.
5 hours of onset, the effect of endovascular embolectomy alone is not inferior to alteplase intravenous thrombolysis combined with endovascular thrombectomy (click to read)
.
at 44 tertiary hospitals in China.
Acute ischemic stroke due to intracranial large vessel occlusion in eligible patients (age≥18 years) had a continuously elevated systolic blood pressure (≥140 mm Hg 10min)
after successful endolectomy and reperfusion.
Patients were randomly assigned (1:1, through a central network program with a minimization algorithm), divided into intensive blood pressure lowering group (systolic blood pressure< 120mmHg) and standard blood pressure group (140~180mmHg), and the systolic blood pressure was controlled to the target range and maintained for 72h within 1h after randomization, and the primary clinical endpoint event was a 90-day functional outcome (mRS score).
The primary efficacy outcome was functional recovery, assessed
as an improved Rankin score distribution (0 [asymptomatic] to 6 [death]) over 90 days.
Analysis was based
on the principle of modified intention-to-treat.
Efficacy analyses were performed using proportional advantage logistic regression, adjusting for treatment allocation to fixed-effect, site for random-effects, baseline prognostic factors, including all randomised patients who provided consent and available data
for primary outcomes.
The safety analysis included all randomly assigned patients
.
The therapeutic effect is expressed
in odds ratio.
Between July 20, 2020 and March 7, 2022, 821 patients were randomly assigned
.
Due to ongoing efficacy and safety concerns, the trial was discontinued
on June 22, 2022, after reviewing the outcome data.
407 patients were assigned to the intensive treatment group and 409 patients were assigned to the low intensive treatment group, of which 404 patients in the intensive treatment group and 406 patients in the low intensive treatment group had preliminary prognostic data
.
Studies have shown that in patients with successful reperfusion after mechanical thrombectomy (eTICI 2b/2c/3) of large-vessel occlusive acute ischemic stroke, intensive postoperative antihypertensive therapy may result in a decrease in functional prognosis of 90 days, i.
e.
, mRS 0-2 ratio (adjusted OR 1.
37 [95% CI 1.
07–1.
76]) and may lead to early neurological deterioration (adjusted OR 1.
53 [95% 1.
18– 1.
97) and higher 90-day disability (OR 2.
07 [95% CI 1.
47–2.
93]), but there was no significant difference
in the proportion of symptomatic bleeding transformation between groups.
Thus, systolic blood pressure should be avoided below 120 mm Hg to prevent affecting functional recovery
in patients with acute ischaemic stroke who undergo endovascular thrombectomy due to intracranial large vessel occlusion.
90-day postoperative Rankin scale score distribution in the treatment group (Figure from Lancet) In summary, the results of this study confirmed that intensive blood pressure lowering may lead to a decrease in the prognosis ratio of mRS function at 90 days compared with standard blood pressure reduction, and the study explored the lower safe limit of blood pressure management (120mmHg) for the first time, which provided high-level evidence support
for blood pressure management after mechanical thrombectomy and recanalization of acute ischemic stroke.
Professor Yang Pengfei and Professor Zhang Yongwei and Professor Song Lili of The George Institute for Global Health are the co-first authors of the study, and Professor Liu Jianmin and Professor Craig Anderson are the co-corresponding authors
.
Original link: (22) 01882-7/fulltext
—END—
The content is 【iNature】
