Pharmacologic elevation of blood pressure for acute brain ischemia.
BACKGROUND
Several studies demonstrated that patients with low blood pressure upon presentation with acute ischemic stroke have worse outcomes. Elevated mean arterial pressure (MAP) directly improves cerebral perfusion. Phenylephrine is a selective alpha-1 agonist with peripheral vasoconstrictive effect, raising the blood pressure without constricting brain vessels.


METHODS
We report a 63-year-old lady presenting with an acute high carotid T occlusion causing hemispheric ischemia that was completely reversed by implementing blood pressure augmentation with fluids and intravenous phenylephrine.


RESULTS
She arrived 4 h after symptoms onset. At its nadir, the NIHSS was 17. Head CT did not reveal hemorrhage or acute ischemic changes. CT angiogram confirmed the presence of a right internal carotid artery occlusion at the level of the neck. Hemodynamic support in the form of IV normal saline was initiated, followed by a bolus of phenylephrine. The patient responded to blood pressure augmentation with marked improvement in her level of consciousness, therefore an infusion of phenylephrine at 140 mcg/min titrated to a MAP of 110-120 mmHg was begun. There was complete resolution of the left hemiparesis less than an hour later.


CONCLUSIONS
This case lends support to the growing body of literature that sustains the use of pharmacological blood pressure augmentation to treat acute brain ischemia. Patients with cervical carotid occlusion represent the ideal candidates for hemodynamic augmentation treatment, as collateral flow can recruited from multiple pathways.
Stead
Latha G
LG
Division of Emergency Medicine Research, Mayo Clinic College of Medicine, Rochester, MN, USA. Stead.Latha@mayo.edu
Bellolio
M Fernanda
MF
Gilmore
Rachel M
RM
Porter
Alyx B
AB
Rabinstein
Alejandro A
AA
D000208:Acute Disease; D001794:Blood Pressure / Q000187:drug effects*; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000503:physiopathology; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000188:drug therapy; D002560:Cerebrovascular Circulation / Q000187:drug effects / Q000502:physiology*; D005260:Female; D006801:Humans; D008875:Middle Aged; D010656:Phenylephrine / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
D014662:Vasoconstrictor Agents; D010656:Phenylephrine