Clinical Neurology and Neurosurgery 224 (2023) 107540

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Clinical Neurology and Neurosurgery

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Effect of blood pressure on the prognosis of acute ischemic stroke patients

caused by anterior circulation large vessel occlusion without recanalization
Tao Luo a, Jun Shuan Cui b, Han Peng b, Xin Xiang b, Yuan Xu b, Hua Yang b, *
a
Clinical Medical College of Guizhou Medical University, Guizhou, China.
b
Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China.

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: To explore the effect of blood pressure on the prognosis of acute ischemic stroke patients caused by
Acute ischemic stroke anterior circulation large vessel occlusion without recanalization.
Large vessel occlusion Methods: Acute ischemic stroke patients caused by anterior circulation large vessel occlusion without recanali­
Blood pressure
zation were retrospectively collected. All patients were divided into the functional independent group and non-
Prognosis
functional independent group, death group and non-death group based on the 90-day mRS score. Logistic
regression was applied to analyze the relationship between the highest systolic blood pressure, the average
systolic blood pressure, the lowest systolic blood pressure, the highest diastolic blood pressure, the average
diastolic blood pressure, the lowest diastolic blood pressure in the first 24 h after admission and the functional
prognosis as well as the complications after 90 days. The independent impact factors selected from regression
analysis were used to investigate the blood pressure with prognostic value by receiver operating characteristic
curve (ROC).
Results: A total of 70 patients were recruited in this study. Among them, 39 cases (55.71%) were male and 31
cases (44.29%) were female, with a mean age of 61.83 ± 15.24 years old. 15 cases (21.43%) had a favorable 90-
day outcome, and the other 55 cases (78.57%) had a higher mRS Score. After a 90-day follow-up, univariate
analysis showed that hypertension and hyperlipidemia, highest systolic blood pressure, mean systolic blood
pressure and NIHSS score were statistically significant in two groups with or without functional independence,
while the NIHSS score at admission, systolic blood pressure at admission, average systolic blood pressure, highest
systolic blood pressure and diastolic blood pressure were statistically significant in patients with death outcomes
(P < 0.05). Multivariate regression analysis suggested that the highest systolic blood pressure was statistically
significant (P < 0.05), the further ROC curve results showed the cut-off value of the highest systolic blood
pressure was 180.5 mmHg, with a sensitivity of 82.35% and a specificity of 81.13%. The highest Youden’s index
was 0.6348.
Conclusion: For acute ischemic stroke patients caused by anterior circulation large vessel occlusion without
recanalization, the appropriate reduction of blood pressure within 24 h after admission may have a positive
effect on the clinical prognosis. The 90-day mortality of acute ischemic stroke patients without revascularization
was independently related to the highest systolic blood pressure. The risk of death was increased when the
highest systolic blood pressure was greater than 180.5 mmHg.

1. Introduction stroke among Chinese residents was 0.15%, accounting for 22.33% of
the total number of deaths. Ischemic stroke accounts for about 70% of
Stroke is one of the most common acute neurological diseases, which the stroke population, and in patients with ischemic stroke, acute large
is the leading cause of disability and death worldwide. According to the vessel occlusion stroke is the most severe type with the worst prognosis
global burden of disease study, the Chinese population has the highest [3]. Acute large vessel occlusion stroke such as internal carotid artery,
lifetime risk of stroke [1]. Based on a Chinese stroke report in 2019 [2], middle cerebral artery, basilar artery and intracranial vertebral artery is
the morbidity of stroke is approximately 1.6%, and the mortality of determined as the underlying etiology in approximately 30–40% of

* Corresponding author at: Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China.
E-mail address: [email protected] (H. Yang).

https://doi.org/10.1016/j.clineuro.2022.107540
Received 24 August 2022; Received in revised form 26 October 2022; Accepted 23 November 2022
Available online 30 November 2022
0303-8467/© 2022 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
T. Luo et al. Clinical Neurology and Neurosurgery 224 (2023) 107540

ischemic strokes, contributing to 60% of post-stroke dependence and Perioperative stroke in the context of major cardiovascular surgery; (6)
death at 90 days [4,5]. mRS≥ 4 before the stroke onset; (7) Incomplete or missing data; (8)
The first line standard of care for patients with acute ischemic stroke Stenosis of the internal carotid artery or cerebral artery.
within 4.5 h of symptom onset remains intravenous thrombolysis [6].
Intravenous thrombolysis, mechanical thrombectomy and other treat­ 2.3. Data collection
ment approaches have significantly improved the recanalization rate of
blood vessels, thus improving the clinical outcome of patients. However, The clinical data were collected and analyzed in this study, including
thrombolysis therapy has a low utilization rate owing to its narrow (1) basic information: age, gender, telephone and other information; (2)
therapeutic time window and low recanalization rate for acute large medical record information: symptoms at onset, onset time, mRS score
vessel occlusion stroke [7]. Besides, these treatment methods have their at admission, NIHSS score at admission, mRS score at discharge and
disadvantages, some patients may refuse to accept the thrombolysis. NIHSS score at discharge; (3) previous medical history and personal
Therefore, some clinic patients with acute large vessel occlusion stroke history: cardiovascular and cerebrovascular risk factors, such as hyper­
did not undergo thrombolysis therapy. tension, hyperlipidemia, coronary heart disease, diabetes, atrial fibril­
Although some risk factors that may affect the clinical prognosis of lation and rheumatic heart disease, and previous cardiovascular and
acute large vessel occlusion stroke patients, such as age [8], higher cerebrovascular surgery; (4) emergency imaging data at admission:
National Institutes of Health Stroke Scale (NIHSS) score [9], lower cranial CT and CTA.
Alberta stroke program early CT Score [10], collateral circulation [11], All patients were monitored in the intensive care unit for more than
thrombus load [12], and operation time [13], most of them are unad­ 24 h. Their blood pressure was monitored every 15 min by a multi-lead
justable in the clinic. Burgeoning studies have confirmed that blood electrocardiogram, the data of blood pressure such as systolic/diastolic
pressure is an important factor in the prognosis of stroke patients [14]. blood pressure was collected for 24 h after the onset of the disease
At present, hemodynamics has been widely considered in acute large (recorded per hour). The lowest, average and highest systolic and dia­
vessel occlusion stroke patients with recanalization [15,16], while few stolic blood pressure of the patients during blood pressure monitoring
studies have been performed on the hemodynamics of acute large vessel were recorded. For the patients who had unexplained deterioration of
occlusion stroke patients without recanalization. It remains elusive the neurological function or new signs such as headache and vomiting, head
effect of blood pressure on the clinical outcomes of acute large vessel CT should be immediately reexamined to check whether there was large-
occlusion stroke patients without recanalization. scale cerebral infarction or brain hernia, which helped us to adjust the
Here, we conducted a retrospective study, including 445 patients therapeutic strategy in time. The cerebral hernia was defined as the
with acute ischemic stroke who did not receive the intravenous throm­ deformation or disappearance of the suprasellar cistern, annular cistern
bolysis and/or mechanical thrombectomy. In the present study, we aim and quadrigeminal cistern on a CT scan.
to investigate the effect of blood pressure on the prognosis of acute
ischemic stroke patients caused by anterior circulation large vessel oc­ 2.4. Outcome assessment
clusion without recanalization, exploring the effect of blood pressure on
the clinical indicators of patients without recanalization within 24 h The mRS score 90 days after treatment was used as the evaluation
after admission. We hope this study could provide basic information to standard to determine recovery of neurological function. Here, the 90-
guide the blood pressure management of this cohort in the clinic. day mRS score after acute ischemic stroke was applied to evaluate the
prognosis of neurological function. An mRS score of 0–2 was defined as a
2. Methods good functional prognosis, and an mRS score of 3–6 was defined as a
poor prognosis [17]. The mRS score was recorded by a neurologist who
2.1. Subjects followed up with patients by telephone or clinic visits during 90 days
after the onset of acute ischemic stroke.
This study was a retrospective study that included 445 patients with Based on the mRS score and post-operative cranial CT results, all
acute ischemic stroke who were admitted continuously to the Depart­ patients were divided into two different groups, including mRS 0–2 and
ment of Neurology, emergency, interventional department and neuro­ mRS 3–6 (refers to the functional independent group and non-functional
surgery in Affiliated Hospital of Guizhou Medical University from independent group, respectively), and death group and non-death
December 2016 to March 2021. This study was approved by the Ethics group.
Committee of Affiliated Hospital of Guizhou Medical University
[approval number: 2020(210)]. Consent was waived for all patients for 2.5. Statistical analysis
this retrospective analysis.
SPSS 25.0 statistical software (SPSS Inc., Chicago, IL) was used for
2.2. Inclusion and exclusion criteria data analysis. Continuous variables conforming to normal distribution
were shown as（χ ± S）; an independent t-test was used for comparison
These patients were then screened based on the inclusion and between the two groups. As for the measurement data that don’t
exclusion criteria. The inclusion criteria were as follows: (1) All the conform to the normal distribution, they were represented as median
patients have accepted head CT and computed tomography angiography and interquartile range, and the rank sum test was utilized for the
(CTA) examination by 64-row CT machine. The thickness of CT layer comparison between the two groups. Categorical variable data were
was 1.25 mm, then the three-dimensional reconstruction was performed expressed in the number of cases and percentages, and were compared
in axial, sagittal and coronal planes to clarify the diagnosis of large using the chi-square test.
vessel occlusion; (2) Acute cerebral infarction occurred within 24 h after Logistic regression was applied to analyze the relationship between
onset; (3) Aged＞18 years; (4) The occluded vessel is the first or second the highest systolic blood pressure, the average systolic blood pressure,
segment of the internal carotid artery and the middle cerebral artery; (5) the lowest systolic blood pressure, the highest diastolic blood pressure,
The patients did not receive the intravenous thrombolysis and/or me­ the average diastolic blood pressure, the lowest diastolic blood pressure
chanical thrombectomy. in the first 24 h after admission and the functional prognosis as well as
The exclusion criteria were as follows: (1) Existing other advanced the complications after 90 days. Odds ratio (OR) and 95% confidence
diseases, such as advanced cancer; (2) Heart failure or liver failure; (3) interval (CI) were calculated to determine the potential association, and
Left ventricular assist device was used before stroke onset; (4) Previous a P-value of < 0.05 was considered statistically significant. The inde­
history of cerebral infarction or cerebral hemorrhage and sequelae; (5) pendent impact factors selected from regression analysis were used to

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investigate the blood pressure with optimal prognostic value by the Table 1
receiver operating characteristic curve and the Youden index. Baseline characteristics of the subjects.
Baseline information mean±SD/n%/IQR
3. Results
Age（ χ ± S，year） 61.83 ± 15.24
Male [case（%）] 39（55.71）
3.1. Patients’ baseline characteristics Female [case（%）] 31（44.29）
Medical history
A total of 445 patients diagnosed with acute ischemic stroke in the Hypertension [case（%）] 43（61.42）
Hyperlipidemia [case（%）] 6（8.57）
Affiliated Hospital of Guizhou Medical University from December 2016 Diabetes [case（%）] 12（17.14）
to March 2021 were collected, among them, 70 cases that met the in­ Coronary heart disease [case（%）] 8（11.43）
clusion and exclusion criteria were recruited, and the patient flow chart Atrial fibrillation [case（%）] 12（17.14）
was shown in Fig. 1. The baseline information such as age, gender, NIHSS score at admission [M（P25,P75）score] 11.00（8.00,16.25）
Blood pressure
medical history, NIHSS and blood pressure were summarized in Table 1.
Systolic blood pressure at admission [χ ± S，mmHg] 157.46 ± 26.62
There were 39 male (55.71%) and 31 female cases (44.29%) with an Diastolic blood pressure at admission [χ ± S，mmHg] 96.73 ± 16.37
average age of 61.83 ± 15.24 years old in this study. 43 (61.42%) of Highest systolic blood pressure [χ ± S，mmHg] 175.77 ± 20.90
them had a medical history of hypertension, 6 (8.57%) had a medical Highest diastolic pressure [χ ± S，mmHg] 107.27 ± 12.64
history of hyperlipidemia, 12 (17.14%) had diabetes, 8 (11.43%) had Mean systolic blood pressure [χ ± S，mmHg] 137.44 ± 16.44
Mean diastolic pressure [χ ± S，mmHg] 80.07 ± 8.85
coronary heart disease and 12 (17.14%) had atrial fibrillation. The mean Lowest systolic blood pressure [χ ± S，mmHg] 114.90 ± 19.20
NIHSS score at admission was 11. The systolic blood pressure at Lowest diastolic pressure [χ ± S，mmHg] 63.94 ± 10.72
admission was 157.46 ± 26.62 mmHg, and the diastolic blood pressure Large vessel occlusion type
at admission was 96.73 ± 16.37 mmHg. The location of large vessel Middle cerebral artery M1 segment [case（%）] 29（41.43）
Middle cerebral artery M2 segment [case（%）] 12（17.14）
occlusion was detected as follows: 29 cases (41.43%) had a large vessel
Internal carotid artery [case（%）] 25（35.71）
occlusion in the middle cerebral artery M1 segment, 12 (17.14%) cases Series occlusion [case（%）] 4（5.71）
were located in the middle cerebral artery M2 segment, the occlusion of Complication
25 (35.71%) cases were found in the internal carotid artery and 4 Cerebral hernia [case（%）] 15（21.43）
(5.71%) cases were shown as series occlusion. 15 patients (21.43%) Outcome
Death within 90 days [case（%）] 21（30.00）
manifested the severe complication of cerebral hernia. A total of 15
patients (21.43%) were functionally independent after 90 days of
follow-up, 34 patients (48.57%) had obvious neurological dysfunction, 3.2. mRS score
and 21 patients died 90 days after onset (Table 1).
The mRS score results at 90-day follow-up were represented in Fig. 2.
Among all patients, 15 cases (21.43%) had a favorable 90-day outcome

Fig. 1. Patient flow chart.

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Table 2
Univariate analysis of patients’ baseline and neurological function at 90 days of
onset.
Independent variable Functional Non-functional P-
independent independent group value
group

Age（ χ ± S，year） 57.00 ± 13.51 63.50 ± 15.57 0.120a

Male [case（%）] 10（55.56） 29（55.77） 0.987b
Female [case（%）] 8（44.44） 23（44.23）
Medical history
Hypertension [case 7（38.89） 36（69.23） 0.023b
（%）]
Hyperlipidemia [case 4（22.22） 2（3.85） 0.016b
（%）]
Diabetes [case（%）] 3（16.67） 9（17.31） 0.950b
Coronary heart disease 1（5.56） 7（13.46） 0.364b
[case（%）]
Atrial fibrillation [case 2（0.00） 10（22.64） 0.431b
（%）]
Fig. 2. mRS scores were followed up for 90 days. NIHSS score at admission 8.50 13.00 0.003c
[M（P25,P75）score] （3.00,11.25） （9.00,18.00）
Blood pressure
(mRS score 0–2 points), and other 55 cases (78.57%) had a higher mRS Systolic blood pressure at 147.61 ± 20.33 160.87 ± 27.84 0.068a
Score. admission [χ ± S，
mmHg]
Diastolic blood pressure 94.50 ± 15.88 97.50 ± 16.62 0.507a
3.3. Predictor analysis at admission [χ ± S，
mmHg]
The patients were divided into functional independent group and Highest systolic blood 166.50 ± 9.55 178.98 ± 22.80 0.028a
non-functional independent group based on the function condition after pressure [χ ± S，
mmHg]
90 days of follow-up. As shown in Table 2, the baseline indexes such as
Highest diastolic pressure 102.94 ± 10.04 108.77 ± 13.18 0.092a
age, gender, medical history and blood pressure were analyzed by uni­ [χ ± S，mmHg]
variate analysis, the factors that predicted a worse outcome were med­ Mean systolic blood 129.89 ± 13.53 140.06 ± 16.66 0.023a
ical history including hypertension and hyperlipidemia, highest systolic pressure [χ ± S，
blood pressure, mean systolic blood pressure and NIHSS score mmHg]
Mean diastolic pressure 78.83 ± 9.95 80.50 ± 8.49 0.495a
(P < 0.05). No significant difference was found in sex, age, diabetes, [χ ± S，mmHg]
atrial fibrillation, coronary heart disease, systolic blood pressure and Lowest systolic blood 115.00 ± 15.11 114.87 ± 20.56 0.980a
diastolic blood pressure at admission, mean diastolic blood pressure, pressure [χ ± S，
highest diastolic blood pressure, lowest systolic blood pressure and mmHg]
Lowest diastolic pressure 65.06 ± 9.72 63.56 ± 11.11 0.618a
diastolic blood pressure (P > 0.05).
[χ ± S，mmHg]
Moreover, we further divided all patients into the death group and
the non-death group based on their outcomes after a 90-day follow-up. Note: a refers to the independent sample t-test, b means chi-square test, and c is
The baseline indexes such as age, gender, medical history and blood the rank-sum test; significant difference was found in hypertension, hyperlip­
idemia, highest systolic blood pressure, average systolic blood pressure and
pressure were analyzed by univariate analysis, the results showed that
NIHSS score at admission between two groups (P < 0.05).
the NIHSS score at admission, systolic blood pressure at admission,
mean systolic blood pressure, highest systolic blood pressure and dia­
stolic blood pressure were significantly different between the two groups relationship between blood pressure and mortality risk, the univariate
(P < 0.05), while no obvious difference was found in gender, age, hy­ regression analysis showed that the correlation between mean systolic
pertension, hyperlipidemia, coronary heart disease, atrial fibrillation, blood pressure, highest systolic blood pressure, highest diastolic blood
diastolic blood pressure at admission, mean diastolic blood pressure, pressure and the mortality risk was statistically significant (P < 0.05),
lowest systolic blood pressure and diastolic blood pressure (P > 0.05) multivariate regression analysis also suggested that the highest systolic
(Table 3). blood pressure was statistically significant (P < 0.05) (Table 5).

3.4. Follow-up outcome 3.5. Prognostic value of blood pressure

The duration of clinical follow-up was 90 days. The logistic regres­ We also investigated the diagnostic value of the highest systolic
sion model was used to analyze the correlation between blood pressure blood pressure by ROC curve here. The results showed that the cut-off
and functional independent outcomes or mortality risk. Univariate lo­ value of the highest systolic blood pressure was 180.5 mmHg, with a
gistic regression analysis was firstly utilized to analyze the factors with sensitivity of 82.35% and a specificity of 81.13%. The highest Youden’s
statistical differences, then the multivariate logistic regression analysis index was 0.6348 (Fig. 3).
was further performed to exclude the possible confounding factors.
The results of the correlation analysis between blood pressure and 4. Discussion
function independence after 90 days were shown in Table 4. Univariate
regression analysis indicated a significant correlation between the Several classic therapeutic approaches such as intravenous throm­
highest systolic blood pressure, the mean systolic blood pressure and the bolysis and mechanical thrombectomy have been widely utilized in the
functional independence after a 90-day follow-up (P < 0.05). However, recanalization of blood vessels in patients with acute ischemic stroke
no statistical significance was found in the highest systolic blood pres­ patients caused by anterior circulation large vessel occlusion [18]. For
sure and the mean systolic blood pressure by multivariate regression example, both of Chang JY et al. and Maier IL have explored the rela­
analysis (P > 0.05). tionship between BP and clinical outcome patients with stroke after
The logistic regression analysis model was applied to analyze the receiving recanalization [19,20]. However, there are still a considerable

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Table 3 Table 4
Univariate analysis of blood pressure level and risk of death. Univariate and multivariate regression analyses of blood pressure and functional
Independent variable Death group Non-death P-value
independence after 90 days.
group Independent variable Univariate regression Multivariate regression
analysis analysis
Age（ χ ± S，year） 67.71 ± 14.71 59.94 ± 15.06 0.067a
Male [case（%）] 9（52.94） 30（56.60） 0.791b OR (95% CI) P- OR (95% CI) P-
Female [case（%）] 8（47.06） 23（43.40） Value Value
Medical history
Hypertension [case（%）] 12（70.59） 31（58.49） 0.373b Systolic blood pressure at 0.981 (0.960 0.073
Hyperlipidemia [case 0（0.00） 6（11.32） 0.147b admission －1.002)
（%）] [χ ± S，mmHg]
Diabetes [case（%）] 4（23.53） 8（15.09） 0.422b Diastolic blood pressure 0.989 (0.956 0.501
Coronary heart disease [case 3（17.65） 5（9.43） 0.354b at admission －1.022)
（%）] [χ ± S，mmHg]
Atrial fibrillation [case 5（29.41） 7（13.21） 0.123b Mean systolic blood 0.962 (0.930 0.029 0.977（0.926 0.385
（%）] pressure －0.996) －1.030）
NIHSS score at admission 24.00 10.00 < 0.001c [χ ± S，mmHg]
[M（P25,P75）score] （14.00,35.00） （7.00,13.00） Mean diastolic pressure 0.979 (0.921 0.489
Blood pressure [χ ± S，mmHg] －1.040)
Systolic blood pressure at 168.47 ± 27.94 153.92 ± 25.45 0.049a Highest systolic blood 0.970 (0.943 0.037 0.985（0.943 0.483
admission [χ ± S， pressure －0.998) －1.028）
mmHg] [χ ± S，mmHg]
Diastolic blood pressure at 103.24 ± 18.99 94.64 ± 15.05 0.059a Highest diastolic 0.960 (0.915 0.097
admission [χ ± S， pressure －1.008)
mmHg] [χ ± S，mmHg]
Highest systolic blood 192.00 ± 15.94 170.57 ± 19.69 < 0.001a Lowest systolic blood 1.000 (0.973 0.979
pressure [χ ± S，mmHg] pressure －1.029)
Highest diastolic pressure 113.88 ± 11.25 105.15 ± 12.42 0.012a [χ ± S，mmHg]
[χ ± S，mmHg] Lowest diastolic pressure 1.014 (0.960 0.608
Mean systolic blood 145.71 ± 15.19 134.79 ± 16.07 0.016a [χ ± S，mmHg] －1.072)
pressure Note: Univariate regression analysis indicated that the highest systolic blood
[χ ± S，mmHg]
a pressure and the mean systolic blood pressure had statistical significance with
Mean diastolic pressure 83.24 ± 7.63 79.06 ± 9.03 0.090
the functional independence after 90-day follow-up (P < 0.05). No statistical
[χ ± S，mmHg]
Lowest systolic blood 118.24 ± 115.64 113.83 ± 20.23 0.414a significance was found by multivariate regression analysis (P > 0.05).
pressure [χ ± S，mmHg]
Lowest diastolic pressure 63.06 ± 6.74 64.23 ± 11.76 0.699a
[χ ± S，mmHg] Table 5
Univariate and multivariate regression analyses of blood pressure and risk of
Note: a refers to independent sample t-test, b means chi square test, and c is rank-
death.
sum test; significant difference was found in NIHSS score at admission, systolic
blood pressure at admission, mean systolic blood pressure, highest systolic blood Independent variable Univariate regression Multivariate regression
pressure and diastolic blood pressure between two groups (P < 0.05). analysis analysis

OR (95% CI) P OR (95% CI) P

number of patients who have not been treated with intravenous Value Value
thrombolysis or mechanical thrombectomy, or some patients refused to Systolic blood pressure at 1.023(0.999 0.073
accept recanalization treatment. For this population, we speculated that admission －1.047)
the relationship between blood pressure and clinical outcome in patients [χ ± S，mmHg]
Diastolic blood pressure at 1.034(0.998 0.066
without recanalization might be similar to that in patients with recan­ admission －1.073)
alization, which has been proven to relate to the highest systolic blood [χ ± S，mmHg]
pressure. It has been confirmed that the highest systolic blood pressure Mean systolic blood 1.052(1.008 0.021 0.974（0.916 0.408
was lower in functional independent patients while higher in patients pressure －1.098) －1.036）
[χ ± S，mmHg]
with death outcomes [21]. Therefore, we investigated the effect of blood
Mean diastolic pressure 1.061(0.990 0.489
pressure on the prognosis of acute ischemic stroke patients caused by [χ ± S，mmHg] －1.138)
anterior circulation large vessel occlusion without recanalization. Our Highest systolic blood 1.070(1.030 0.037 1.089（1.027 0.004
findings showed that the 90-day mortality of acute ischemic stroke pa­ pressure [χ ± S，mmHg] －1.111) －1.154）
tients without revascularization was independently related to the Highest diastolic pressure 1.060(1.009 0.020 0.998（0.933 0.943
[χ ± S，mmHg] －1.113) －1.067）
highest systolic blood pressure, the risk of death was increased when the Lowest systolic blood 1.014(0.981 0.409
highest systolic blood pressure was greater than 180.5 mmHg. pressure [χ ± S，mmHg] －1.049)
In the present study, there was no statistical difference in sex and age Lowest diastolic pressure 0.990(0.943 0.695
between two groups with or without functional independence or death. [χ ± S，mmHg] －1.040)
The highest systolic blood pressure was lower in the functional inde­ Note: Univariate regression analysis indicated that the mean systolic blood
pendent group (166.50 ± 9.55 mmHg vs 178.98 ± 22.80 mmHg), and pressure, highest systolic blood pressure and highest diastolic blood pressure
the highest systolic and diastolic blood pressure of patients with death had statistical significance with the mortality risk after 90-day follow-up
outcomes were higher after a 90-day follow-up (192.00 ± 15.94 mmHg (P < 0.05). Multivariate regression analysis showed that the highest systolic
vs 170.57 ± 19.69 mmHg; 113.88 ± 11.25 vs 105.15 ± 12.42 mmHg, blood pressure was statistically significant (P > 0.05).
respectively). Our findings were consistent with the relevant studies of
acute ischemic stroke patients with recanalization by mechanical study, the results identified that reduced blood pressure after recanali­
thrombectomy, both populations with lower highest systolic and dia­ zation was associated with smaller infarct volume and possibly better
stolic blood pressure showed a more favorable prognosis, while the clinical outcomes [25]. During the onset of acute ischemic stroke,
acute ischemic stroke patients with the death outcome have higher collateral circulation plays an important role in compensation, thus
highest systolic and diastolic blood pressure [22–24]. In an animal sufficient blood pressure is of great significance for maintaining the

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that this may be related to the second type of error due to the relatively
limited sample size in this study. Besides, it is also possible that the
highest systolic blood pressure may only slightly improve the hand or
language function of patients without revascularization, and these im­
provements cannot be quantified by mRS scores. What’s more, most
previous studies targeted the subjects who failed to recanalize during
mechanical thrombectomy, while our patients without vessel recanali­
zation did not undergo intravenous thrombolysis or mechanical
thrombectomy.
The prognostic value of blood pressure was also evaluated in this
study by the ROC curve. We identified that the most effective cut-off
value of the highest systolic blood pressure to prognose the death
outcome was 180.5 mmHg, with a sensitivity of 82.35% and a specificity
of 81.13%, it is indicated that patients with maximum systolic blood
pressure higher than 158 mmHg may have a poor prognosis. Our finding
emphasized that the patient without vessel recanalization who kept a
high blood pressure could maintain cerebral perfusion, however,
Fig. 3. The ROC curve for highest systolic blood pressure and risk of death. excessive elevated blood pressure may increase the mortality due to the
damage to capillary cells, leading to increased vascular permeability and
perfusion of ischemic brain tissue. However, excessively high blood blood extravasation in the brain parenchyma [31,32]. This is related to
pressure may induce the aggravation of cerebral edema and the the aggravation of cerebral edema, further inducing cerebral ischemia. It
compression of blood vessels, aggravating the blood flow perfusion of is demonstrated that some ischemic stroke patients with increased blood
ischemic brain tissue, and ultimately leading to a poor clinical prog­ pressure after intravenous thrombolysis or mechanical thrombolysis
nosis. This process could also be used to explain that the patients with a treatment may have poor prognosis at the early stage, which is related to
relatively favorable outcome usually have lower blood pressure, and the expansion of infarct lesions and the aggravation of cerebral edema
their risk of some complications such as cerebral edema, cerebral hernia [33,34]. Collectively, our findings elucidated the negative effect of the
and cerebral hemorrhage is also low. highest systolic blood pressure levels on the functional prognosis and
Burgeoning studies have reported the diagnostic and prognostic mortality outcome in acute ischemic stroke patients without recanali­
value of blood pressure in patients with acute ischemic stroke. Anadany zation [23].
et al.[26] indicated that the anterior circulation ischemic stroke patients There are some limitations in this study. First, this is a single-center
with systolic blood pressure < 120 mmHg at 24 h after operation had a study with relatively small sample size. Next, it is a retrospective study
better prognosis and lower mortality after 90 days of follow-up than which may have some methodological defects. Last, due to most of the
patients with systolic blood pressure ≥ 120 mmHg. The DAWN trial patients who have dysfunction during the follow-up refusing to re-
proposed to maintain the systolic blood pressure around 140 mmHg in examine the head CTA, we cannot obtain the condition of blood vessel
patients with anterior circulation ischemic stroke [27]. Schonewille WJ compensation in the later period after treatment, hindering the analyses
et al. [28] conducted a double center retrospective study, and their re­ on the blood pressure, collateral circulation and clinical results.
sults showed that the patient’s clinical outcome could be better when the For acute ischemic stroke patients caused by anterior circulation
median systolic blood pressure was less than140mmHg, with a lower large vessel occlusion without recanalization, the appropriate reduction
90-day mortality rate. In the current study, we noticed that our subjects of blood pressure within 24 h after admission may have a positive effect
with independent function or death outcome owned a relatively higher on the clinical prognosis. The 90-day mortality of acute ischemic stroke
blood pressure level than patients with recanalization reported previ­ patients without revascularization was independently related to the
ously. We hypothesized this phenomenon may be caused by the recan­ highest systolic blood pressure. The risk of death was increased when the
alization condition of blood vessels. After the occlusion of large blood highest systolic blood pressure was greater than 180.5 mmHg. When the
vessels, the blood pressure will rise responsively to maintain cerebral highest systolic blood pressure is greater than 180.5 mmHg, the risk of
perfusion. When the occlusion of blood vessels is recanalized, the blood death will be increased. Therefore, blood pressure could be considered
pressure will drop spontaneously. Some studies suggested that patients an important adjustable index to help improve the prognosis of patients
need a higher blood pressure level to maintain collateral perfusion in the with acute ischemic stroke who did not accept recanalization therapy.
ischemic area when the degree of vascular recanalization is TICI 2b after
mechanical thrombectomy [23]. Blood pressure is one of the most dy­ CRediT authorship contribution statement
namic physiological variables after acute ischemic stroke patients
caused by large vessel occlusion, various internal and external factors Tao Luo: Ideas, Data collecting, Data curation, Writing. Cui Jun
could induce the short fluctuation of blood pressure, for instance, central Shuan : Data collecting, Data curation. Han Peng : Data collecting. Xin
sympathetic drive, arterial tension, cardiopulmonary reflex, blood vis­ Xiang : Data collecting, Software. Yuan Xu: Methodology, Data audit­
cosity, volume status and drugs [29,30]. Thus, blood pressure could be ing, Software. Hua Yang: Ideas, Supervision, Writing − review &
considered as an important adjustable index to help improve the prog­ editing.
nosis of patients with acute ischemic stroke.
The close correlation between the highest systolic blood pressure and
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