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Letter by Samuels et al Regarding Article, "Decreases in Blood Pressure During Thrombectomy Are Associated With Larger Infarct Volumes and Worse Functional Outcome".

To the Editor: Petersen et al evaluated the role of hypotension during endovascular treatment (EVT) and its associations with infarct progression and functional outcome. The authors found that blood pressure reduction before recanalization is associated with larger infarct volumes and worse functional outcomes. The results of their observational study address the importance of blood pressure monitoring and management during EVT. We consider this an interesting study that addresses topical questions. Nevertheless, we do have some comments. The authors solely evaluated blood pressure data from patients who underwent EVT receiving anesthesia, either in the form of conscious sedation (CS; 65%) or general anesthesia (GA; 35%). Patients receiving local anesthesia (LA) at the groin puncture site only were not mentioned in this study. It is already known that intraprocedural hypotensive episodes are associated with worse outcomes for both CS and GA, possibly attributed to the administered agents (eg, propofol) which secondarily induce blood pressure reductions. For this reason, LA could be a safer anesthetic strategy with respect to hemodynamic stability. Moreover, in the HERMES meta-analysis (Highly Effective Reperfusion Using Multiple Endovascular Devices Collaboration), non-GA was associated with better outcomes than GA. However, this non-GA group was defined as the composite of LA and CS. The better functional outcomes in the non-GA arm might thus well be the result of patients receiving LA only. Recently, we compared the effect of LA only during EVT to CS and found that patients receiving LA reported better functional outcomes. Therefore, LA deserves more attention in comparable analyses. This is an observational study. Readers may be tempted to reason that reversal or prevention of the blood pressure drop will result in an effect on outcome of the same magnitude but in opposite direction as observed in this study. This is not likely to be true because vasopressors are often needed to treat blood pressure drops and a detrimental effect of prolonged vasoconstriction in acute ischemic stroke has been suggested. More data on hemodynamic interventions during EVT is needed to understand the underlying pathway causing the poor outcomes in patients with blood pressure drops. In conclusion, it remains important to avoid hypotension during EVT in patients receiving CS or GA. Because the association between anesthetic management and functional outcome could partially be explained by intraprocedural hypotension, we propose that future trials consider LA as a treatment arm besides CS and GA, with strict monitoring of blood pressure and hemodynamic interventions.