The effect of glucose–potassium–insulin (GKI) infusion on the blood pressure and hormonal response to acute stroke

Over the last two decades, there have been a number of major landmark clinical trials, classified as “major” as they sought to address clear clinical practice driven questions, in a pragmatic yet robust trial design, using a large powered sample size (n > 1000), in order to help improve patient outcome through informing guidelines. A commonality across all stroke sub-types included in these trials is the tendency to acute hypertensive crises within the acute stroke period. This phenomenon is associated with greater stroke complications and worsened overall prognosis. Multiple trials have attempted to address the issue of acute blood pressure management during the acute stroke period, with consideration for timing, magnitude of lowering, agent and relationship to other interventions. This review will consider the major clinical trials performed in ischaemic and haemorrhagic stroke that test the hypothesis that acute BP reduction improves clinical outcomes.

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Response: High Blood Pressure in Acute Stroke and Subsequent Outcome: A Systematic Review

Hypertension ◽

10.1161/01.hyp.0000127307.52793.e0 ◽

2019 ◽

Author(s):

Mark Willmot ◽

Jo Leonardi-Bee ◽

Philip M.W. Bath

Keyword(s):

Systematic Review ◽

Blood Pressure ◽

Acute Stroke ◽

High Blood Pressure

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101 Case report: to stent, or not to stent? The pale cast of evidence-based practice in acute stroke

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-anzan.89 ◽

2019 ◽

Vol 90 (e7) ◽

pp. A33.1-A33

Author(s):

Chris Blair ◽

Kartik Bhatia ◽

David Brunacci ◽

John Worthington ◽

Rebekah Ahmed

Keyword(s):

Blood Pressure ◽

Acute Stroke ◽

Evidence Based Practice ◽

Blood Pressure Monitoring ◽

Neurological Deficits ◽

Evidence Based ◽

Limb Weakness ◽

Vasopressor Support ◽

Course Of Action ◽

The Right

IntroductionWith approximately 200 procedures performed in the last year at our centre, worthwhile clinical lessons continue to emerge in the practice of endovascular clot retrieval (ECR) for acute stroke. This case demonstrates the value of considered clinical appraisal in a dynamic, information-rich setting. A 68 year-old man with established vertebrobasilar atherosclerotic disease developed capricious, blood pressure-sensitive neurological deficits after successful ECR for a basilar artery stroke, inviting the possibility of further intervention in the form of intracranial stenting. We avoided pursuing this course of action in favour of a more measured approach, entailing the provision of vasopressor support over the following week.MethodFollowing ECR, our patient was admitted to the intensive care unit for continuous blood pressure monitoring and close observation of his neurological deficits with serial NIHSS (National Institutes of Health Stroke Scale) scoring. Systolic blood pressures were maintained between 140–160 mmHg using vasopressor support, with the aim of allowing time for recovery of vascular autoregulation and collateralization.ResultsOver six days, the patient developed moderate left upper and lower limb weakness. An MRI performed on Day 5 revealed limited interval infarction of the right hemipons and cerebellum, with complete re-occlusion of the mid-basilar arterial segment. He left the ICU with a NIHSS score of 7, and was living independently at 90-day follow-up (Modified Rankin Score 1).ConclusionThe ultimately favourable net outcome for our patient clearly illustrates the imperative to remain within the boundaries of evidence-based practice in this bold and rapidly evolving discipline.

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Twenty-four hour systolic blood pressure predicts long-term mortality following acute stroke

Journal of Hypertension ◽

10.1097/00004872-200112000-00003 ◽

2001 ◽

Vol 19 (12) ◽

pp. 2127-2134 ◽

Cited By ~ 57

Author(s):

Thompson G. Robinson ◽

Suzanne L. Dawson ◽

Usman Ahmed ◽

Brad Manktelow ◽

Martin D. Fotherby ◽

...

Keyword(s):

Blood Pressure ◽

Systolic Blood Pressure ◽

Acute Stroke ◽

Long Term Mortality

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Baseline characteristics of the 1149 patients recruited into the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) randomized controlled trial

International Journal of Stroke ◽

10.1177/1747493018816451 ◽

2018 ◽

Vol 14 (3) ◽

pp. 298-305 ◽

Cited By ~ 1

Author(s):

Philip M Bath ◽

Polly Scutt ◽

Jason P Appleton ◽

Mark Dixon ◽

Lisa J Woodhouse ◽

...

Keyword(s):

Blood Pressure ◽

Glyceryl Trinitrate ◽

Acute Stroke ◽

Controlled Trial ◽

Nitric Oxide Donor ◽

Main Trial ◽

Randomized Controlled ◽

Baseline Characteristics ◽

The Uk ◽

Stroke Trial

Background High blood pressure is common in acute stroke and associated with a worse functional outcome. Glyceryl trinitrate, a nitric oxide donor, lowers blood pressure in acute stroke and may improve outcome. Aims Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) tested the feasibility of performing a UK multicenter ambulance-based stroke trial, and the safety and efficacy of glyceryl trinitrate when administered by paramedics before hospital admission. Methods Paramedic-led ambulance-based multicenter prospective randomized single-blind blinded-endpoint parallel-group controlled trial of transdermal glyceryl trinitrate (given for four days) versus sham in patients with ultra-acute (<4 h) presumed stroke. Data are number (%), median (interquartile range) or mean (standard deviation). Results Recruitment ran from October 2015 to 31 May 2018. A total 1149 patients were recruited from eight UK ambulance services and taken to 54 acute hospitals. Baseline characteristics include: mean age 73 (15) years; female 555 (48%); median time from stroke to randomization 70 (45, 115) min; face-arm-speech scale score 2.6 (0.5); and blood pressure 162 (25)/92 (18) mmHg. The final diagnosis was ischemic stroke 52%, hemorrhagic stroke 13%, Transient Ischemic Attack (TIA) 9%, and mimic 25%. The main trial results will be presented in quarter 4 2018. The results will also be included in updated Cochrane systematic reviews, and individual patient data meta-analyses of all relevant randomized controlled trials. Conclusion It was feasible to perform a multicenter ambulance-based ultra-acute stroke trial in the UK and to treat with glyceryl trinitrate versus sham. The relatively unselected cohort of stroke patients is broadly representative of those admitted to hospital in the UK. Trial registration ISRCTN26986053.

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Insights into a personalized management of blood pressure in acute stroke

Current Opinion in Neurology ◽

10.1097/wco.0000000000001016 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Rajiv Advani ◽

Else Charlotte Sandset

Keyword(s):

Blood Pressure ◽

Acute Stroke ◽

Personalized Management

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Abstract WP245: Hyperacute Blood Pressure Variability is Associated with Early Neurological Deterioration

Stroke ◽

10.1161/str.48.suppl_1.wp245 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Joseph Kim ◽

Jeffrey L Saver ◽

David S Liebeskind ◽

Sidney Starkman ◽

Scott Hamilton ◽

...

Keyword(s):

Blood Pressure ◽

Emergency Department ◽

Cerebral Ischemia ◽

Acute Stroke ◽

Symptom Onset ◽

Blood Pressure Variability ◽

Final Diagnosis ◽

Controlled Study ◽

Double Blind ◽

Neurologic Deterioration

Background: Increased blood pressure variability (BPV) has been associated with worse outcomes in acute stroke. The effect of hyperacute (<4 hours) BPV on early neurologic deterioration (END) has not been described. Objective: To investigate whether BPV in the first hours after stroke onset is associated with END from prehospital evaluation to presentation at the emergency department Methods: All patients enrolled in the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 trial were included. FAST-MAG was a multicenter, randomized, double-blind, placebo-controlled study looking at whether initiation of magnesium sulfate (20 grams/24 hours) in the prehospital setting of acute stroke would reduce disability. Study agent was initiated prior to hospital arrival < 2 hours from symptom onset. BPV was defined as the standard deviation of systolic blood pressure of all readings obtained by 4 hours after initiation of study agent. END was diagnosed as Glasgow Coma Scale (GCS) decrease by ≥ 2 points between the prehospital evaluation and post-emergency department arrival assessment by a study nurse. Results: There were 1,700 cases evaluated by paramedics 24 minutes (15-45 IQR), and by study nurses 150 minutes (120-180) after symptom onset with a median of 6 (IQR 5-6) BP readings. The mean (±SD) age was 69±13 years, 42.6% were women, and the median prehospital GCS was 15 (IQR 14-15). The final diagnosis was cerebral ischemia in 73.3% of patients, intracranial hemorrhage in 22.8%, and a stroke-mimicking condition in 3.9%. END was seen in 202 (12%) of subjects, with higher rates noted in those with intracerebral hemorrhage (ICH) compared to cerebral ischemia (31% vs 6%). Overall, there was greater BPV in patients with END (23mmHg vs 15mmHg, p<0.001). Blood pressure variability was greater in cases of cerebral ischemia with END (N=1,245, 18mmHg vs 15mmHg, p=0.004) and in ICH cases with END (N=387, 23mmHg vs 15mmHg, p<0.001). Conclusion: Greater blood pressure variability is associated with early neurologic deterioration in patients with cerebral ischemia and ICH evaluated <2 hours from symptom onset.

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Abstract TMP12: Does Prehospital Magnesium Sulfate Differentially Improve Outcome in Hyperacute Stroke Patients With Higher Pretreatment Blood Pressure?

Stroke ◽

10.1161/str.47.suppl_1.tmp12 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Phoebe H Johnson-Black ◽

Sidney Starkman ◽

Nerses Sanossian ◽

David Liebeskind ◽

Samuel Stratton ◽

...

Keyword(s):

Blood Pressure ◽

Cerebrovascular Disease ◽

Acute Stroke ◽

Magnesium Sulfate ◽

Controlled Trial ◽

Functional Independence ◽

Forest Plot ◽

Stroke Patients ◽

Improve Outcome ◽

Acute Cerebral Ischemia

Introduction: Magnesium sulfate (Mg) has blood pressure (BP) lowering, cerebral blood flow enhancing, and neuroprotective effects in preclinical and clinical studies. In the IMAGES phase 3 trial, Mg up to 12h after onset showed no benefit in acute stroke, but was associated with improved outcome in patients with higher blood pressure at entry. Hypothesis: We tested the hypothesis that ultra-early Mg improves functional outcome in acute stroke patients with higher baseline BP. Methods: FAST-MAG is a multicenter, double-blind, randomized, placebo-controlled trial of paramedic-initiated Mg, administered to patients with suspected stroke within 2h of symptom onset. The primary analysis showed neutral effect of Mg. This secondary analysis examines rates of functional independence (mRS 0-2) at 3m for Mg and placebo for different field BP groups. Results: Among 1622 patients with acute cerebrovascular disease, age was 69.6 (±13.4), 42% female, entry deficit severity in the field was LAMS 3.8 (±1.2), and first post-enrollment NIHSS in the ED was 11.5 (±9.9). Systolic blood pressure prior to enrollment was higher among patients with intracerebral hemorrhage (ICH) than acute cerebral ischemia (ACI), 175 (±25) vs 155 (±27), p < .001. The Figure shows the Forest plot for Mg vs placebo and functional independence among blood pressure groups. Heterogeneity of treatment effect was noted in the all-cerebrovascular patients population (p < .01), with fewer independent outcomes with Mg than placebo among patients with higher entry BPs. Analysis of Functional Independence (mRS 0-2) at 90 Days in Prespecified Subgroups Conclusion: This analysis did not confirm the prior finding of magnesium sulfate benefit among acute stroke patients with elevated blood pressure (and actually provided a signal in the opposing direction). Mg was not demonstrated to improve outcome when started in the first 2h of onset among patients with acute cerebrovascular disease and higher blood pressures.

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