Misery perfusion, blood pressure control, and 5-year stroke risk in symptomatic major cerebral artery disease

The benefit of strict blood pressure (BP) control in high-risk patients with symptomatic major cerebral artery disease and misery perfusion (MP) is controversial. Our purposes were (1) to determine whether MP is a predictor of a 5-year risk of subsequent stroke and (2) to investigate the relationships among BP during follow-up, MP, and the stroke risk.

We studied 130 nondisabled patients with symptomatic major cerebral artery disease. Baseline hemodynamic measurements were obtained from (15)O-gas positron emission tomography, and patients received medical treatment and they were followed for 5 years or until stroke recurrence or death.

During 5 years, strokes occurred in 6 of 16 patients with MP and in 15 of 114 without MP (log-rank test; P<0.01). There were 4 (25%) ipsilateral ischemic strokes in patients with MP and 4 in those without MP (P<0.001). The risk of ipsilateral ischemic stroke declined markedly after 2 years, and there was only 1 ipsilateral ischemic stroke in a patient without MP. Normal systolic BP (<130 mm Hg) was associated with an increased risk of ipsilateral ischemic strokes in patients with impaired perfusion (including MP), whereas systolic BP outside the 130 to 149 mm Hg range was associated with an increased risk of all strokes in patients without MP.

Patients with MP showed a high-5-year stroke recurrence, but a large part of the 5-year stroke risk disappeared after 2 years. Aggressive BP control may be hazardous in patients with impaired perfusion, including MP.