Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Special Issue: Current evidence and perspectives for hypertension management in Asia
  • Published:

The impact of blood pressure variability on the development of parenchymal hematoma in acute cerebral infarction with atrial fibrillation

Hypertension Research volume 47, pages 618–627 (2024)Cite this article

Abstract

Although blood pressure variability (BPV) and reperfusion are associated with parenchymal hematoma (PH) after stroke, the relationship between BPV and PH in atrial fibrillation (AF) patients who are at risk of reperfusion injury with frequent spontaneous recanalization is unknown. This study aimed to investigate whether BPV within the first 48 h is associated with PH within 72 h in patients with AF and stroke in terms of major vessel occlusion status. A total of 131 patients with AF that were admitted within 24 h after stroke onset were enrolled. PH was defined as a confluent hemorrhage with mass effect. The maximum (max), minimum (min), and average blood pressure (BP) during the first 48 h after admission were calculated. BPV was analyzed by using range between maximum and minimum (max–min), successive variation (SV), standard deviation (SD), and coefficient of variation (CV). All parameters were applied for systemic (SBP), diastolic (DBP), and pulse pressure (PP). After adjusting for confounding variables, various BPV parameters were associated with PH, including SBPmax (p = 0.0426), SBPSV (p = 0.0006), DBPmax-min (p = 0.0437), DBPSV (p = 0.0358), DBPSD (p = 0.0393), PPmax-min (p = 0.0478), PPSV (p < 0.0001), PPSD (p = 0.0034), and PPCV (p = 0.0120). The relationship remained significant in patients with a patent major vessel responsible for infarction but not in patients with an occluded major vessel. In conclusion, this study revealed that high BPV was associated with PH in patients with AF and acute stroke, particularly for those with a patent major vessel. The control of BP and BPV after stroke may be considered in patients with AF.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1

Similar content being viewed by others

References

  1. Fiorelli M, Bastianello S, von Kummer R, del Zoppo GJ, Larrue V, Lesaffre E, et al. Hemorrhagic transformation within 36 h of a cerebral infarct: relationships with early clinical deterioration and 3-month outcome in the European Cooperative Acute Stroke Study I (ECASS I) cohort. Stroke. 1999;30:2280–4.

    Article  CAS  PubMed  Google Scholar 

  2. Paciaroni M, Agnelli G, Corea F, Ageno W, Alberti A, Lanari A, et al. Early hemorrhagic transformation of brain infarction: rate, predictive factors, and influence on clinical outcome: results of a prospective multicenter study. Stroke. 2008;39:2249–56.

    Article  PubMed  Google Scholar 

  3. Simard JM, Kent TA, Chen M, Tarasov KV, Gerzanich V. Brain oedema in focal ischaemia: molecular pathophysiology and theoretical implications. Lancet Neurol. 2007;6:258–68.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Stokum JA, Gerzanich V, Simard JM. Molecular pathophysiology of cerebral edema. J Cereb Blood Flow Metab. 2016;36:513–38.

    Article  CAS  PubMed  Google Scholar 

  5. Ko Y, Park JH, Yang MH, Ko SB, Han MK, Oh CW, et al. The significance of blood pressure variability for the development of hemorrhagic transformation in acute ischemic stroke. Stroke. 2010;41:2512–8.

    Article  PubMed  Google Scholar 

  6. Yong M, Kaste M. Association of characteristics of blood pressure profiles and stroke outcomes in the ECASS-II trial. Stroke. 2008;39:366–72.

    Article  PubMed  Google Scholar 

  7. Liu K, Yan S, Zhang S, Guo Y, Lou M. Systolic blood pressure variability is associated with severe hemorrhagic transformation in the early stage after thrombolysis. Transl Stroke Res. 2016;7:186–91.

    Article  CAS  PubMed  Google Scholar 

  8. Kim TJ, Park HK, Kim JM, Lee JS, Park SH, Jeong HB, et al. Blood pressure variability and hemorrhagic transformation in patients with successful recanalization after endovascular recanalization therapy: a retrospective observational study. Ann Neurol. 2019;85:574–81.

    Article  CAS  PubMed  Google Scholar 

  9. Khatri R, McKinney AM, Swenson B, Janardhan V. Blood-brain barrier, reperfusion injury, and hemorrhagic transformation in acute ischemic stroke. Neurology. 2012;79:S52–7.

    Article  PubMed  Google Scholar 

  10. Yang P, Song L, Zhang Y, Zhang X, Chen X, Li Y, et al. Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet. 2022;400:1585–96.

    Article  PubMed  Google Scholar 

  11. Matusevicius M, Cooray C, Bottai M, Mazya M, Tsivgoulis G, Nunes AP, et al. Blood pressure after endovascular thrombectomy: modeling for outcomes based on recanalization status. Stroke. 2020;51:519–25.

    Article  PubMed  Google Scholar 

  12. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute Ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–418.

    Article  PubMed  Google Scholar 

  13. Sun J, Lam C, Christie L, Blair C, Li X, Werdiger F, et al. Risk factors of hemorrhagic transformation in acute ischaemic stroke: a systematic review and meta-analysis. Front Neurol. 2023;14:1079205.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Tu HT, Campbell BC, Christensen S, Desmond PM, De Silva DA, Parsons MW, et al. Worse stroke outcome in atrial fibrillation is explained by more severe hypoperfusion, infarct growth, and hemorrhagic transformation. Int J Stroke. 2015;10:534–40.

    Article  PubMed  Google Scholar 

  15. Aryal R, Patabendige A. Blood-brain barrier disruption in atrial fibrillation: a potential contributor to the increased risk of dementia and worsening of stroke outcomes? Open Biol. 2021;11:200396.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Molina CA, Montaner J, Abilleira S, Ibarra B, Romero F, Arenillas JF, et al. Timing of spontaneous recanalization and risk of hemorrhagic transformation in acute cardioembolic stroke. Stroke. 2001;32:1079–84.

    Article  CAS  PubMed  Google Scholar 

  17. Adams HP Jr., Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute stroke treatment. Stroke. 1993;24:35–41.

    Article  PubMed  Google Scholar 

  18. Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA. MR signal abnormalities at 1.5 T in Alzheimer’s dementia and normal aging. AJR Am J Roentgenol. 1987;149:351–6.

    Article  CAS  PubMed  Google Scholar 

  19. Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355:1670–4.

    Article  CAS  PubMed  Google Scholar 

  20. Neuberger U, Kickingereder P, Schonenberger S, Schieber S, Ringleb PA, Bendszus M, et al. Risk factors of intracranial hemorrhage after mechanical thrombectomy of anterior circulation ischemic stroke. Neuroradiology. 2019;61:461–9.

    Article  PubMed  Google Scholar 

  21. Alvarez-Sabin J, Maisterra O, Santamarina E, Kase CS. Factors influencing haemorrhagic transformation in ischaemic stroke. Lancet Neurol. 2013;12:689–705.

    Article  PubMed  Google Scholar 

  22. Zhang J, Yang Y, Sun H, Xing Y. Hemorrhagic transformation after cerebral infarction: current concepts and challenges. Ann Transl Med. 2014;2:81.

    PubMed  PubMed Central  Google Scholar 

  23. Yang M, Pan X, Liang Z, Huang X, Duan M, Cai H, et al. Association between blood pressure variability and the short-term outcome in patients with acute spontaneous subarachnoid hemorrhage. Hypertens Res. 2019;42:1701–7.

    Article  PubMed  Google Scholar 

  24. Kamieniarz-Medrygal M, Lukomski T, Kazmierski R. Short-term outcome after ischemic stroke and 24-h blood pressure variability: association and predictors. Hypertens Res. 2021;44:188–96.

    Article  CAS  PubMed  Google Scholar 

  25. Toyoda K, Yamagami H, Kitagawa K, Kitazono T, Nagao T, Minematsu K, et al. Blood pressure level and variability during long-term prasugrel or clopidogrel medication after stroke: PRASTRO-I. Stroke. 2021;52:1234–43.

    Article  CAS  PubMed  Google Scholar 

  26. Nepal G, Shrestha GS, Shing YK, Muha A, Bhagat R. Systolic blood pressure variability following endovascular thrombectomy and clinical outcome in acute ischemic stroke: a meta-analysis. Acta Neurol Scand. 2021;144:343–54.

    Article  PubMed  Google Scholar 

  27. Avolio AP, Kuznetsova T, Heyndrickx GR, Kerkhof PLM, Li JK. Arterial flow, pulse pressure and pulse wave velocity in men and women at various ages. Adv Exp Med Biol. 2018;1065:153–68.

    Article  PubMed  Google Scholar 

  28. Levin RA, Carnegie MH, Celermajer DS. Pulse pressure: an emerging therapeutic target for dementia. Front Neurosci. 2020;14:669.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Park JH, Lee J, Kwon SU, Sung Kwon H, Hwan Lee M, Kang DW. Elevated pulse pressure and recurrent hemorrhagic stroke risk in stroke with cerebral microbleeds or intracerebral hemorrhage. J Am Heart Assoc. 2022;11:e022317.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Selker HP, Beshansky JR, Schmid CH, Griffith JL, Longstreth WT Jr., O’Connor CM, et al. Presenting pulse pressure predicts thrombolytic therapy-related intracranial hemorrhage. Thrombolytic Predictive Instrument (TPI) Project results. Circulation. 1994;90:1657–61.

    Article  CAS  PubMed  Google Scholar 

  31. Katsanos AH, Alexandrov AV, Mandava P, Kohrmann M, Soinne L, Barreto AD, et al. Pulse pressure variability is associated with unfavorable outcomes in acute ischaemic stroke patients treated with intravenous thrombolysis. Eur J Neurol. 2020;27:2453–62.

    Article  CAS  PubMed  Google Scholar 

  32. Kamieniarz-Medrygal M, Kazmierski R. Significance of pulse pressure variability in predicting functional outcome in acute ischemic stroke: a retrospective, single-center, observational cohort study. Sci Rep. 2023;13:3618.

    Article  CAS  PubMed  PubMed Central  ADS  Google Scholar 

  33. Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, et al. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord. 2021;14:17562864211021182.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in patients with atrial fibrillation. N. Engl J Med. 2011;365:981–92.

    Article  CAS  PubMed  Google Scholar 

  35. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N. Engl J Med. 2009;361:1139–51.

    Article  CAS  PubMed  Google Scholar 

  36. Mehta RH, Cox M, Smith EE, Xian Y, Bhatt DL, Fonarow GC, et al. Race/Ethnic differences in the risk of hemorrhagic complications among patients with ischemic stroke receiving thrombolytic therapy. Stroke. 2014;45:2263–9.

    Article  CAS  PubMed  Google Scholar 

  37. Shen AY, Yao JF, Brar SS, Jorgensen MB, Chen W. Racial/ethnic differences in the risk of intracranial hemorrhage among patients with atrial fibrillation. J Am Coll Cardiol. 2007;50:309–15.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

This study was supported by a grant from the Kaohsiung Medical University Hospital (grant numbers: KMUH111–1M51). The authors thank the help from Dr. Ming-Yen Lin, a biostatistician in the Division of Medical Statistics and Bioinformatics, Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University.

Funding

This study was supported by a grant from the Kaohsiung Medical University Hospital (grant numbers: KMUH111–1M51), but this funding source had no involvement of study design, collection, analysis, and interpretation of results, writing of the report or any restrictions regarding submission.

Author information

Authors and Affiliations

  1. Departments of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

    Meng-Ni Wu, Yi-On Fong, Yi-Hui Lin, Ping-Song Chou, Chung-Yao Hsu & Hsiu-Fen Lin

  2. Departments of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

    Meng-Ni Wu, Ping-Song Chou, Chung-Yao Hsu & Hsiu-Fen Lin

  3. Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

    Meng-Ni Wu & Yu-Peng Liu

  4. Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

    Yu-Peng Liu

  5. Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

    I-Hsiao Yang

  6. Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

    Ping-Song Chou

Authors
  1. Meng-Ni Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yu-Peng Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yi-On Fong
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yi-Hui Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. I-Hsiao Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ping-Song Chou
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Chung-Yao Hsu
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Hsiu-Fen Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hsiu-Fen Lin.

Ethics declarations

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wu, MN., Liu, YP., Fong, YO. et al. The impact of blood pressure variability on the development of parenchymal hematoma in acute cerebral infarction with atrial fibrillation. Hypertens Res 47, 618–627 (2024). https://doi.org/10.1038/s41440-023-01479-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41440-023-01479-5

Keywords

This article is cited by

Search

Advanced search

Quick links