Association of Postprocedural Systolic Blood Pressure Peaks with Symptomatic Intracranial Hemorrhage after Thrombectomy with Emergent Carotid Stenting for Tandem Lesions: An Exploratory Multicenter Cohort Study

BACKGROUND AND PURPOSE: Symptomatic intracranial hemorrhage remains a relevant complication after thrombectomy with emergent carotid stenting for tandem lesions. We assessed whether recurrent postprocedural systolic blood pressure peaks were associated with ECASS III symptomatic intracranial hemorrhage. MATERIALS AND METHODS: high-volume stroke centers between June 2015 and January 2020. Patients were continuously monitored on intermediate care, intensive care, or stroke units by invasive arterial monitoring or automated noninvasive measurements every 10 minutes. Primary exposure was recurrent postprocedural SBP >140 mm Hg within 48 hours, excluding care-related elevations, lasting ≥10 minutes during invasive monitoring or occurring in ≥2 consecutive cuff measurements. RESULTS: After excluding patients without postprocedural blood pressure data, 217 patients were analyzed. Mean age was 71.0 years. Radiographic hemorrhagic transformation including HI2, PH1, and PH2 occurred in 58/217 patients, and symptomatic intracranial hemorrhage occurred in 15/217. Neither known hypertension nor admission hypertension was associated with symptomatic intracranial hemorrhage. Antithrombotic variables included in the present analysis showed no significant univariable association with symptomatic intracranial hemorrhage. In multivariable logistic regression, postprocedural systolic blood pressure peaks in patients without known hypertension were independently associated with symptomatic intracranial hemorrhage (adjusted OR, 7.45; 95% CI, 1.39-39.79; P=.02), whereas peaks in patients with known hypertension were not significantly associated with symptomatic intracranial hemorrhage (adjusted OR, 3.03; 95% CI, 0.61-15.20; P=.18). At 90-day follow-up, 11/15 patients with symptomatic intracranial hemorrhage had died, and the remaining 4/15 had a modified Rankin Scale score of 5. CONCLUSIONS: Recurrent postprocedural systolic blood pressure peaks were associated with symptomatic intracranial hemorrhage after thrombectomy with emergent carotid stenting, particularly in patients without known hypertension. Reverse causality cannot be excluded; these hypothesis-generating findings warrant prospective evaluation with standardized time-stamped blood pressure, clinical, and imaging data.