Blood pressure boost can help ischemic stroke patients. (Departure from Standard Care).

DENVER -- Temporarily inducing blood pressure elevations in patients with acute or subacute ischemic strokes resulted in reperfusion of ischemic brain tissue--and significantly improved function--in a small prospective, randomized trial.

The best candidates for this novel therapy appear at this point to be patients with ischemic stroke involving stenosis of a large vessel and a resultant large area of hypoperfused but not infarcted tissue, Dr. John A. Ulatowski said at the annual meeting of the American Academy of Neurology.

"We didn't take all comers," emphasized Dr. Ulatawski of Johns Hopkins University, Baltimore, in his presentation of the results of a 15-patient pilot study sponsored by the National Institutes of Health.

Participants were randomized 2:1 to either pharmacologic blood pressure elevation or conventional management. The blood pressure increase was achieved using intravenous phenylephrine as needed to raise mean arterial pressure by 10% increments up to 140 mm Hg. Twenty-four hours after patients started showing improvement, they were weaned off this aggressive intravenous regimen and onto oral therapy with fludrocortisone, midodrine, and salt tablets.

Patients in the treatment group had improvements, going from a mean NIH Stroke Score of 10.2 at baseline on day 1 to 5.5 on day 3. Their error rate on objective cognitive testing fell from 48% on day l to 29% on day 3. Their mean volume of hypoperfused tissue on brain imaging dropped from 125 to 71 cc. These improvements were maintained at 6-8 weeks follow-up. None of these parameters showed significant change in the control group.

In seven of nine treated patients, mean arterial pressure was strongly correlated with the results of daily cognitive testing, suggesting that the observed functional improvement was tied to the changes in blood pressure, Dr. Ulatowski said.

Deliberately raising blood pressure in a patient with vascular disease is contrary to standard care. No cardiac events occurred in the study subjects, but the trial did not include patients with heart failure, bradycardia, or recent myocardial ischemia.

The concept of inducing blood pressure elevation in order to improve function after stroke isn't new, but it isn't widely known and hasn't previously been evaluated in a randomized trial with brain imaging. The results of this pilot study warrant a much larger double-blind, randomized trial, he concluded.

Among the questions that need to be addressed is how long the therapy should be continued, Dr. Ulatowski said. A couple of patients in the pilot trial developed symptoms during an attempt to wean them off oral therapy after 1 month, so investigators reinstituted the regimen.