Anesthetic variation and potential impact of anesthetics used during endovascular management of acute ischemic stroke

Abstract

Background Multiple authors have reported that “general anesthesia”(GA), as a generic and uncharacterized therapy, is contraindicated for patients undergoing endovascular management of acute ischemic stroke(EMAIS). The recent AHA update cautiously suggests that it might be reasonable to favor conscious sedation over GA during EMAIS. We are concerned that such recommendations will result in patients undergoing endovascular treatment without consideration of the effects of specific anesthetic agents, anesthetic dose, nor appropriate critical consideration of the individual patient's issues. We hypothesized that significant variation in anesthetic practice comprises GA and that outcome differences among types of GA would arise. Methods With IRB approval we examined records of patients who underwent anterior circulation EMAIS at UPenn from 2010 to 2015. Patients were managed by different anesthesiologists with no specific protocol. We analyzed ASA status, NIHSS, type of stroke, procedure, different types of anesthetic, blood pressure control, and outcome metrics. Modified Rankin Scales(mRS) were determined from medical records. Results GA was used in 91% of patients. Several types of GA were employed: intravenous(TIVA), volatile, and intravenous/volatile(combined). mRS scores ≤2 at discharge were observed in 42.8% of our patients receiving volatile anesthesia and were better in patients receiving only volatile agents after induction of anesthesia (P<0.05). Conclusion Our data support the notion that anesthetic techniques and associated physiology used in EMAIS are not homogenous, making any statements about the effects of generic “GA” in stroke ambiguous. Moreover, our data suggest that the type of GA may affect outcome after EMAIS.

A decrease in blood pressure is associated with unfavorable outcome in patients undergoing thrombectomy under general anesthesia

“…Previous studies examined the occurrence of such single extreme blood pressure values. One did find significant associations with outcome,17 while others could not 18 19. Another study investigating both patients under conscious sedation and GA found lower minimum diastolic blood pressures in patients with worse outcome 20.…”

Anaesthesia practices for endovascular therapy of acute ischaemic stroke: a Nordic survey

“…[12][13][14][15][18][19][20][21][22][23] Interestingly, a recent study suggested that volatile anaesthetics were associated with a better outcome in patients subjected to EVT interventions for AIS. The retrospective studies have only reported GA as a generic and uncharacterized therapy.…”

“…18 Thirdly, the preferred method of anaesthesia for EVT may have changed, now favouring the use of CS. This finding may partly be explained by the substantial number of past retrospective studies suggesting worse neurological outcome and even increased mortality in patients subjected to EVT in GA. [12][13][14][15][20][21][22][23][24] However, most of these studies were biased because as GA was often selected for patients with more severe illness, thus prone to worse outcome. The extent to which the degree of stroke deficit influenced the decision of CS vs. GA among Nordic anaesthetic departments was not answered by this questionnaire.…”

“…[12][13][14][15][18][19][20][21][22][23] Interestingly, a recent study suggested that volatile anaesthetics were associated with a better outcome in patients subjected to EVT interventions for AIS. 21 In our investigation the combination of propofol and remifentanil was most commonly (61%) used for GA followed by propofol/fentanyl or propofol (22%) alone and sevoflurane/remifentanil (17%). In this survey, a variety of drugs were used for CS and most departments reported the use of midazolam, fentanyl, propofol and remifentanil either in combinations or administered alone.…”

Reconceptualising stroke research to inform the question of anaesthetic neurotoxicity

“…26 This is significant because temporary vessel clipping during these surgeries may increase cerebral-ischaemia risk, yet no appreciable neurological deterioration was noted at 24 h [OR 1.155 (95% CI 0.777e1.717); P¼0.475] or 3 months [OR 0.981 (95% CI 0.625e1.368); P¼0.926] with supplemental anaesthetic administration. Nonetheless, anaesthetic variation during endovascular stroke rescue may impact outcomes, 27 and intraoperative burst suppression might be an independent risk factor for postoperative delirium. 28 Final results from the GOLIATH trial may allow for additional evaluation of neurological injury and outcomes in relation to anaesthetic dosing.…”