1. Intern Talk
Nicholas Reynolds

2. Introduction
• BP increased in stroke and usually
decreases spontaneously over time
• BP higher in patients with acute stroke than
other acute illnesses

3. However
• High BP more common in individuals with
stroke than general population
• A) High post-stroke BP
• B) Blood pressure variability

4. Causes for increased
post-stroke HTN
• Disturbed autoregulation
• autonomic reactivity
• neuroendocrine factors
• headache, urinary retention, etc.

5. Troubling point
• The reduction of blood pressure after
acute stroke is of no benefit or slight harm:
ischemic stroke
• Some benefit: intracerebral hemorrhage

6. Troubling point
• No clear physiological explanation for
these findings

7. Hypothesis
• Post-stroke hypertension due to recent
premorbid increase in blood pressure

8. Design
• Oxfordshire from 2002 to 2012
• Determine relation between premorbid
and acute post-event blood pressure in
two stroke subtypes in oxford vascular
study

9. Design
• post-stroke BP
• NIHSS stroke scale >3
• TOAST (Trial of Org 10172 in Acute
ischemic stroke treatment) for subtype
classification
• European guidelines lowered BP only if
>220 mmHg systolic or >120 mmHg
diastolic

10. Analysis
• 1st event only
• Exclusion:TIA, minor stroke (NIH <3)
• mean 10 yr premorbid BP, highest
premorbid BP, visit-visit variability,
coefficient of variation, variation
independent mean
• log(time scale)
• pre-event to post-event comparision using
paired t test

11. Results
• 636 eligible patient
• median premorbid BP measurement: 17 (8-
31 IRQ)
• positive correlation between number
premorbid readings and mean premorbid
systolic BP
• mean premorbid systolic BP > ischemic
stroke (6.5 mmHg CI 0.5-12)
• mean premorbid visit-visit variability SD
16-89 vs 15-13 mmHg) ischemic vs.
hemorrhagic

12. Results
• most recent premorbid systolic BP in
ischemic stroke no greater in period before
stroke BUT systolic BP higher in weeks and
days before intracranial hemorrhage

16. Discussion
• premorbid systolic BP increased in patients
with intracerebral hemorrhage substantially
following stroke
• no difference for ischemic stroke

17. Discussion
• Post-stroke BP higher than most recent
premorbid BP suggesting post-stroke
factors leading to rise - cushing’s response,
stress
• Odd this not seen in ischemic stroke

18. Discussion
• Explanation of equivocal findings of BP
reduction in ischemic stroke
• Highlight need for long-term BP control
especially in prevention of intracerebral
hemorrhage

19. Limitations
• Late presentation
• Post stroke use of antihypertensives
• Measurement error
• no systemic protocol for recording
• exclusions for TIA, minor stroke
• Biphasic intracerebellar hemorrhage peak
suggests a mechanism