Anesthesia for endovascular treatment of acute ischemic stroke

Abstract

The initial treatment of patients with acute ischemic stroke (AIS) focuses on rapid recanalization, which often includes the use of endovascular therapies. Endovascular treatment depends upon micronavigation of catheters and devices into the cerebral vasculature, which is easier and safer with a motionless patient. Unfortunately, many stroke patients are unable to communicate and sufficiently cooperate with the procedure. Thus, general anesthesia (GA) with endotracheal intubation provides an attractive means of keeping the patient comfortable and motionless during a procedure that could otherwise be lengthy and uncomfortable. However, several recent retrospective studies have shown an association between GA and poorer outcomes in comparison with conscious sedation for endovascular treatment of AIS, though prospective studies are lacking. The underlying reasons why GA might produce a worse outcome are unknown but may include hemodynamic instability and hypotension, delays in treatment, prolonged intubation with or without neuromuscular blockade, or even neurotoxicity of the anesthetic agent itself. Currently, the choice between GA and conscious sedation should be tailored to the individual patient, on the basis of neurologic deficits, airway and hemodynamic status, and treatment plan. The use of institutional treatment protocols may best support efficient and effective care for AIS patients undergoing endovascular therapy. Important components of such protocols would include parameters to choose anesthetic modality, timeliness of induction, blood pressure goals, minimization of neuromuscular blockade, and planned extubation at the end of the procedure. Neurology ® 2012;79 (Suppl 1):S167-S173

Clinical Impact of Ventilation Duration in Patients with Stroke Undergoing Interventional Treatment under General Anesthesia: The Shorter the Better?

“…Hence, our own results and data from the literature contradict the above-mentioned hypothesis to some extent. 8,9,21,23 In summary, our results support the hypothesis that intubation per se is a risk factor for pneumonia and unfavorable clinical outcome. Nonetheless, our results are possibly also affected by the small sample size and the non-normal distribution of our data.…”

“…However, data from the literature and a more elaborate interpretation of our results imply that ventilation duration may nevertheless have an impact on clinical outcome. 8,9,21,23 A more thorough insight into our data shows that the missing significance at early and late cutoffs may be partly attributed to the non-normal distribution of our data. In fact, 33 of 42 (78.6%) patients with favorable functional outcome were ventilated for Յ24 hours and only 3 of 42 (7.1%) patients with favorable clinical outcome were ventilated for Ͼ1 week.…”

“…6,7 General anesthesia and intubation, however, allow complete immobilization and comfort of the patient, thereby allowing better image quality. 7,8 On the other hand, it is assumed that delays in door-to-puncture time, development of ventilatorassociated pneumonia, and ventilation-induced hypotension and hypocapnia may negatively influence clinical outcome in patients treated under GA. 9,10 In a recent retrospective study Ͼ500 patients who were treated under GA were matched with patients treated under conscious sedation. 11 Patients with GA were found to have a higher in-hospital mortality and higher rate of pneumonia.…”

Outcomes of General Anesthesia and Conscious Sedation in Endovascular Treatment for Stroke

“…Several literature reviews provide more detail of these issues. [8][9][10] The current study used a retrospective design to compare morbidity and mortality of type of anesthesia in patients who received endovascular treatment in the setting of acute ischemic stroke using CS versus GA.…”

Role of Anesthesia for Endovascular Treatment of Ischemic Stroke

“…The available literature 3,4,[8][9][10][11][12][13][14][15][16][17] suggests that patients who receive GA actually do worse than those who receive CS or monitored anesthesia care. However, it should be recognized that the majority of the retrospective studies report a higher stroke severity in the GA-treated group of patients compared with non-GA patients as measured by the National Institutes of Health Stroke Scale (NIHSS).…”