Neurocritical Care

, Volume 30, Issue 2, pp 372–379 | Cite as

Early Manipulation of Arterial Blood Pressure in Acute Ischemic Stroke (MAPAS): Results of a Randomized Controlled Trial

  • Luiz Antonio NasiEmail author
  • Sheila Cristina Ouriques Martins
  • Miguel Gus
  • Gustavo Weiss
  • Andrea Garcia de Almeida
  • Rosane Brondani
  • Letícia Costa Rebello
  • Angélica DalPizzol
  • Flávio Danni Fuchs
  • Maria Júlia Monteiro Valença
  • Letícia F. Wirth
  • Gerson Nunes
  • Craig S. Anderson
Original Article



There is uncertainty over the optimal level of systolic blood pressure (SBP) in the setting of acute ischemic stroke (AIS). The aim of this study was to determine the efficacy of the early manipulation of SBP in non-thrombolised patients. The key hypothesis under investigation was that clinical outcomes vary across ranges of SBP in AIS.


218 patients were randomized within 12 h of AIS to maintain the SBP during 24 h within three ranges: Group 1 140–160 mmHg, Group 2 161–180 mmHg or Group 3 181–200 mmHg. Vasoactive drugs and fluids were used to achieve these targets. Good outcome was defined as a modified Rankin score 0–2 at 90-days.


The median SBP in the three groups in 24 h was: 153 mmHg, 163 mmHg, and 178 mmHg, respectively, P < 0.0001. Good clinical outcome did not differ among the different groups (51% vs 52% vs 39%, P = 0.27). Symptomatic intracranial hemorrhage (SICH) was more frequent in the higher SBP range (1% vs 2.7% vs 9.1%, P = 0.048) with similar mortality rates. No patient had acute neurological deterioration related to the SBP reduction in the first 24 h. In our logistic regression analysis, the odds of having good clinical outcome was higher in Group 2 (OR 2.83) after adjusting for important confounders. Regardless of the assigned group, the probability of good outcome was 47% in patients who were manipulated to increase the BP, 42% to decrease and 62% in non-manipulated (P = 0.1). Adverse effects were limited to Group 2 (4%) and Group 3 (7.6%) and were associated with the use of norepinephrine (P = 0.05).


Good outcome in 90 days was not significantly different among the 3 blood pressure ranges. After logistic regression analysis, the odds of having good outcome was greater in Group 2 (SBP 161–180 mmHg). SICH occurred more frequently in Group 3 (181–200 mmHg).


Stroke Ischemic stroke Acute stroke Hypertension Blood pressure 



We thank Magda Martins for the continuous support to finish this study.

Authors’ contribution

LAN planned the study, interpreted the data and wrote the first draft of the report. SCOM planned and supervised the study, interpreted the data and wrote the report. MG planned the study, interpreted the data and wrote the report. GW, AGA, RB, LCR, ADP, MJMV, LFW and GN contributed to the report. FDN reviewed and contributed to the report. CSA interpreted the data and wrote the report.

Source of support

This research was supported by Hospital de Clínicas de Porto Alegre and CAPES. The study was designed, conducted, analyzed and interpreted by the investigators independent of sponsors.

Compliance with Ethical Standards

Conflict of interest

C.S.A reports membership of Advisory Boards for Pfizer and The Medicines Company, and receiving travel reimbursement and honorarium from Takeda China and Covidien. The other authors declare no potential conflict of interest.

Ethical Approval

The study was approved by the Ethical Committee of Hospital de Clínicas de Porto Alegre. All patients (or close relative) provided informed consent.

Supplementary material

12028_2018_642_MOESM1_ESM.docx (76 kb)
Supplemental Table 1. Blood pressure manipulation status, drugs and dose according to randomized group (DOCX 76 kb)
12028_2018_642_MOESM2_ESM.png (360 kb)
Supplemental Fig. 1: MAPAS trial design (PNG 360 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  • Luiz Antonio Nasi
    • 1
    Email author
  • Sheila Cristina Ouriques Martins
    • 1
    • 2
  • Miguel Gus
    • 3
  • Gustavo Weiss
    • 1
    • 2
  • Andrea Garcia de Almeida
    • 1
    • 2
  • Rosane Brondani
    • 1
    • 2
  • Letícia Costa Rebello
    • 1
    • 2
  • Angélica DalPizzol
    • 1
    • 2
  • Flávio Danni Fuchs
    • 3
  • Maria Júlia Monteiro Valença
    • 1
    • 2
  • Letícia F. Wirth
    • 1
  • Gerson Nunes
    • 1
  • Craig S. Anderson
    • 4
  1. 1.Vascular Unit, Emergency Department, Hospital de Clínicas de Porto AlegreUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
  2. 2.Stroke Division, Neurology Service, Hospital de Clínicas de Porto AlegreUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
  3. 3.Hypertension Group, Cardiology Service, Hospital de Clínicas de Porto AlegreUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
  4. 4.The George Institute for Global Health, Royal Prince Alfred HospitalUniversity of New South WalesSydneyAustralia

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