The anesthetic approach for endovascular recanalization therapy depends on the lesion site in acute ischemic stroke

Abstract

Purpose Endovascular therapy (EVT) of large-vessel occlusion in acute ischemic stroke (AIS) may be performed in general anesthesia (GA) or conscious sedation (CS). We intended to determine the contribution of ischemic cerebral lesion sites on the physician’s decision between GA and CS using voxel-based lesion symptom mapping (VLSM). Methods In a prospective local database, we sought patients with documented AIS and EVT. Age, stroke severity, lesion volume, vigilance, and aphasia scores were compared between EVT patients with GA and CS. The ischemic lesions were analyzed on CT or MRI scans and transformed into stereotaxic space. We determined the lesion overlap and assessed whether GA or CS is associated with specific cerebral lesion sites using the voxel-wise Liebermeister test. Results One hundred seventy-nine patients with AIS and EVT were included in the analysis. The VLSM analysis yielded associations between GA and ischemic lesions in the left hemispheric middle cerebral artery territory and posterior circulation areas. Stroke severity and lesion volume were significantly higher in the GA group. The prevalence of aphasia and aphasia severity was significantly higher and parameters of vigilance lower in the GA group. Conclusions The VLSM analysis showed associations between GA and ischemic lesions in the left hemispheric middle cerebral artery territory and posterior circulation areas including the thalamus that are known to cause neurologic deficits, such as aphasia or compromised vigilance, in AIS-patients with EVT. Our data suggest that higher disability, clinical impairment due to neurological deficits like aphasia, or reduced alertness of affected patients may influence the physician’s decision on using GA in EVT.

Anesthetic considerations for endovascular treatment in stroke therapy

“…The use of LA was not explicitly asked in the respective survey, but this anesthetic strategy is also employed in multiple CSCs, especially in the Netherlands [12 ▪ ]. A study by Fröhlich et al [13] suggested that the choice of GA over CS is influenced by higher disability, clinical impairment such as aphasia and reduced alertness in affected patients. The variation in use of anesthetic strategy is a consequence of current guidelines stating the optimal anesthetic approach remains undetermined [9,10].…”

“…The results of the nonrandomized studies could be affected by selection bias. Indeed, GA may be chosen for patients with more severe neurological impairment [13]. However, the results of the RCTs should also be interpreted with caution in terms of generalizability.…”