Neurology: Relationship between contrasting enhancement after reperfusion and antihypertensive efficacy in patients with acute ischemic stroke

Observational studies have described a relationship between
higher systolic blood pressure (SBP) values and poorer prognosis following successful reperfusion (EVT) with intracranial haemorrhage (ICH) and endovascular therapy (EVT).
However, the BP-TARGET trial [BP-TARGET reduces bleeding after EVT in acute ischemic stroke] found that enhancing SBP targets did not reduce the incidence
of intracerebral hemorrhage after successful EVT.
Contrast enhancement (CE) immediately after reperfusion is also associated
with a higher chance of intracerebral haemorrhage and a worse prognosis.
A study published in Neurology describes the effects
of two SBP strategies after reperfusion on the incidence and functional prognosis of intracerebral hemorrhage, based on the presence of CE in the BP-TARGET trial.
The study hypothesized that patients with CE could benefit from
enhanced SBP control.

The study included BP-targeted patients who underwent brain plates
immediately after reperfusion.
Describing CE as present or absent, intracerebral hemorrhage included any radiological intracerebral hemorrhage 24 hours after EVT, and adverse outcomes included a modified Rankin score of 3-6
at 3 months.

Of the 324 patients randomized to BP-TARGET, 164 were included in this analysis, of which 113 (68.
9%) developed CE
after reperfusion.
The 24-hour mean systolic intensity group was significantly lower than the standard group (129.
7 versus 138.
3 mm Hg, p<0.
001).

Patients with CE were randomly divided into intensive SBP group and standard SBP group, and the incidence of cerebral hemorrhage increased: AOR=11.
26, 95% confidence interval 4.
59~27.
63, AOR=4.
08, 95% confidence interval 1.
75~9.
50
.
However, the heterogeneity test did not reach a significant level (AOR=2.
76, 95%CI 0.
80~9.
48, p=0.
11).

The probability of poor prognosis of CE patients randomized in the intensive SBP group was also higher (AOR=2.
91, 95%CI 1.
24~6.
82), but this correlation was not significant in the standard SBP group (AOR=1.
89, 95%CI 0.
85~4.
23).

There was no significant difference between the two groups (AOR was 1.
54, 95%CI was 0.
48~4.
97, p=0.
47).

Overall, CE patients randomized in the intensive SBP group did not have a lower incidence of intracerebral haemorrhage or improved prognosis compared with standard SBP because CE was associated with a higher chance of ICH in both groups and there was no significant heterogeneity
.

This study provides grade IV evidence that intensive blood pressure management does not significantly increase the risk of
intracerebral haemorrhage in adults with contrast-enhancing impairment following successful EVT in AIS.

Source: Maïer B, Brauner R, Escalard S, et al.
Association of Contrast Enhancement After Reperfusion With Outcomes According to Blood Pressure Lowering in Acute Ischemic Stroke Patients [published online ahead of print, 2022 Aug 30].
Neurology.
2022; 10.
1212/WNL.
0000000000201173.
doi:10.
1212/WNL.
0000000000201173