Abstract 3180: Hypotensive Events at Stroke Onset in the absence of Severe Carotid Disease
Hypotensive strokes frequently occur in the context of severe carotid disease. Aside from this cohort, evidence is lacking for the role of hypotension in stroke. The aim of this study was to investigate the presence of hypotensive behavior at stroke onset in those who do not have severe carotid disease. Prospective screening was conducted on all acute stroke patients for hypotensive symptoms at stroke onset. Suitable patients were referred to a syncope unit for assessment. There they underwent head-up tilt and rhythm assessment at least 8 weeks post stroke. All underwent 1.5T MRI in the acute stroke period. Where borderzone infarction was suspected repeat 3T MRI took place with perfusion imaging software to confirm this diagnosis. In total, 318 acute stroke patients presented to St. James Hospital, Dublin during a 14 month period. Of these, 20 patients exhibited hypotensive symptoms at stroke onset and did not have severe carotid disease (6.3%). In 12 patients TILT assessment induced symptom reproduction, thus confirming hypotensive behavior,in 2 this occurred during active stand, in 4 expert opinion established a diagnosis of vasovagal syncope while in 1 patient bradyarrythmia and in 1 autonomic failure was attributed. Median carotid stenosis was 20-30% bilaterally (range 10-70%). Ten of 20 patients underwent MRA. No intracranial stenosis was detected. Mean age was 74 years and 70% were female (n=14). Using phasic blood pressure (BP) assessment during active stand the mean BP drop in these patients was 47/26mmhg. Nadir BP drop occurred within 15 seconds in 17 patients (85%) and thus may have gone undetected by a sphygmomanometer. 19 patients reported a prior history of presyncope(95%). The mean duration of symptoms was 4.9 years (0.1-30 years), mean frequency 6 episodes per month. In 13 patients the neurological deficit resolved within 24 hours. An acute infarct was detected in 3 of 13, all borderzone infarction. In 7 patients the deficit persisted beyond 24 hours. An acute infarct was detected in 4 of 7, all borderzone infarction. Both cortical and internal borderone infarcts were detected. Mean 24 hour blood pressure was 143/77. Neither mean BP, nor BP variability statistically differed from 40 age and gender matched stroke controls. Hypotensive symptoms do occur at the time of stroke onset. Patients are often female, describe a prior history of hypotensive symptoms, have hypotensive disorders and exhibit a strong tendency for borderzone infarction. Caution is advised regarding the use of aggressive anti-hypertensive therapy in these patients.
- © 2012 by American Heart Association, Inc.