Abstract
Hemorrhagic transformation remains a potentially catastrophic complication of reperfusion therapies for the treatment of large-vessel occlusion ischemic stroke. Observational studies have found an increased risk of hemorrhagic transformation in patients with elevated blood pressure as well as a high degree of blood pressure variability, suggesting a link between hemodynamics and hemorrhagic transformation. Current society-endorsed guidelines recommend maintaining blood pressure below a fixed threshold of 180/105 mmHg regardless of thrombolytic or endovascular intervention. However, given the high recanalization rates with mechanical thrombectomy, it is unclear if the same hemodynamic goals from the pre-thrombectomy era apply. Also, individual patient factors such as the degree of reperfusion, infarct size, and collateral status likely need to be considered. In this review, we will discuss current evidence linking hemodynamics to hemorrhagic transformation after mechanical thrombectomy. In addition, we will review the clinical relevance of cerebral autoregulation in stroke, highlighting recent studies that have harnessed autoregulatory physiology to define and trend individualized limits of autoregulation. This review will go on to emphasize the translatability of this approach to stroke management. Finally, we will discuss novel statistical approaches like trajectory analysis to post-thrombectomy hemodynamics.
Highlights
Hemorrhagic transformation (HT) is a feared complication of acute ischemic stroke and is independently associated with neurological deterioration and worse functional outcomes [1,2,3,4]
While animal and human studies have invoked pathomechanisms involving neuroinflammation, neurovascular unit impairment, blood brain barrier disruption, and vascular remodeling, this clinically oriented review will focus on cerebral autoregulation and optimal blood pressure (BP) management following endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) acute ischemic stroke [5, 6]
Mechanical thrombectomy preceded by intravenous thrombolytics has become standard of care treatment in stroke patients with acute ischemia secondary to LVO [7]
Summary
Hemorrhagic transformation (HT) is a feared complication of acute ischemic stroke and is independently associated with neurological deterioration and worse functional outcomes [1,2,3,4]. In the first five studies that looked at EVT in the early window (up to 12 h), symptomatic HT in the treatment group ranged from 0 to 7.7% Of note, in these five studies, most patients (>80%) in both intervention and control groups received intravenous thrombolysis in addition to EVT. In these five studies, most patients (>80%) in both intervention and control groups received intravenous thrombolysis in addition to EVT In both extended time window trials, symptomatic hemorrhagic complications occurred in 6–7% of patients in the treatment group. Radiographic hemorrhagic infarction (HI) is common following EVT and has been associated with poor outcome, thereby questioning the purported benign nature of HI [4] While these studies suggest a possible role of hemodynamics in the development of HT, they do not prove a causal relationship. Identification of patients at risk for HT (both radiographic and symptomatic) may allow for early preventative strategies like BP control post-EVT
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