Anaesthesia for Endovascular Treatment of Acute Ischemic Stroke: Still Controversial?
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Purpose of Review
This article reviews recent research on anaesthetic management of acute ischemic stroke revascularization. With emphasis on the effect of anaesthesia type on outcome, we will discuss controversial discoveries and future perspectives.
A substantial number of retrospective observational studies have suggested that general anaesthesia (GA) compared to conscious sedation (CS) is associated with worse outcomes after endovascular therapy for acute ischemic stroke. In contrast, recent randomized trials reported no difference in outcomes in ischemic stroke patients receiving either GA or CS during revascularization with signals in favour of general anaesthesia. Peri-procedural hemodynamic management, ventilation, and choice of anaesthetics are discussed.
Recent evidence suggests that GA may be an equal alternative to CS for stroke thrombectomy. Overall, the optimal anaesthetic technique for the management of endovascular therapy for acute ischemic stroke remains controversial.
KeywordsAnaesthesia Stroke Retrospective studies Randomized studies Endovascular therapy Hemodynamics
Compliance with Ethical Standards
Conflict of Interest
Line K. Rasmussen, Claus Z. Simonsen, Pia Löwhagen Hendén, Julian Bösel, and Mads Rasmussen declare they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 5.• Brinjikji W, Murad MH, Rabinstein AA, Cloft HJ, Lanzino G, Kallmes DF. Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis. Am J Neuroradiol. 2015;36:525–9. Comprehensive meta-analysis of studies published till 2015. CrossRefPubMedGoogle Scholar
- 6.• Löwhagen Hendén P, Rentzos A, Karlsson J-E, Rosengren L, Sundeman H, Reinsfelt B, et al. Hypotension during endovascular treatment of ischemic stroke is a risk factor for poor neurological outcome. Stroke. 2015;46:2678–80. One of the first studies suggesting association between peri-procedural blood pressure and outcome during ischemic stroke thrombectomy. CrossRefPubMedGoogle Scholar
- 7.• Athiraman U, Sultan-Qurraie A, Nair B, Tirschwell DL, Ghodke B, Havenon AD, et al. Endovascular treatment of acute ischemic stroke under general anesthesia: predictors of good outcome. J Neurosurg Anesthesiol. 2017; https://doi.org/10.1097/ANA.0000000000000449. Recent study suggesting influence of ventilation on outcome after ischemic stroke thrombectomy.
- 13.• Abou-Chebl A, Lin R, Hussain M, Jovin T, Levy E, Liebeskind D, et al. Conscious sedation versus general anesthesia during endovascular therapy for acute anterior circulation stroke: preliminary results from a retrospective, multicenter. Stroke. 2010;41:1175–9. One of the earliest and largest retrospective analyses on anesthesia vs. outcome after ischemic stroke thrombectomy. CrossRefPubMedGoogle Scholar
- 14.Jumaa MA, Zhang F, Ruiz-Ares G, Gelzinis T, Malik AM, Aleu A, et al. Comparison of safety and clinical and radiographic outcomes in endovascular acute stroke therapy for proximal middle cerebral artery occlusion with intubation and general anesthesia versus the nonintubated state. Stroke. 2010;41:1180–4.CrossRefPubMedGoogle Scholar
- 16.• Davis MJ, Menon BK, Baghirzada LB, Campos-Herrera CR, Goyal M, Hill MD, et al. Anesthetic management and outcome in patients during endovascular therapy for acute stroke. Anesthesiology. 2012;116:396–405. Retrospective analysis suggesting that systolic blood pressure < 140 mmHg is associated with poor outcome after stroke thrombectomy. CrossRefPubMedGoogle Scholar
- 19.• Berkhemer OA, van den Berg LA, Fransen PSS, Beumer D, Yoo AJ, Lingsma HF, et al. The effect of anesthetic management during intra-arterial therapy for acute stroke in MR CLEAN. Neurology. 2016;87:656–64. Post-hoc analysis of data from the Mr. Clean trial suggesting that GA is associated with loss of thrombectomy treatment effect. CrossRefPubMedGoogle Scholar
- 22.Langner S, Khaw A, Fretwurst T, Angemaier A, Hosten N, Kirch M. Endovascular treatment of acute ischemic stroke under conscious sedation compared to general anesthesia-safety, feasibility and clinical and radiological outcome. Europepmc. 2013;185(4):320–7.Google Scholar
- 29.Campbell BCV, van Zwam WH, Goyal M, Menon BK, Dippel DWJ, Demchuk AM, et al. Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol. 2018;17:47–53.CrossRefPubMedGoogle Scholar
- 33.•• Schönenberger S, Uhlmann L, Hacke W, Schieber S, Mundiyanapurath S, Purrucker JC, et al. Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy a randomized clinical trial. JAMA. 2016;316(19):1986–96. First randomized trial on anesthesia vs. outcome for ischemic stroke thrombectomy. CrossRefPubMedGoogle Scholar
- 34.•• Löwhagen Hendén P, Rentzos A, Karlsson J-E, Rosengren L, Leiram B, Sundeman H, et al. General anesthesia versus conscious sedation for endovascular treatment of acute ischemic stroke. Stroke. 2017;48(6):1601–7. Second randomized trial on anesthesia ve. outcome for ischemic stroke thrombectomy. CrossRefPubMedGoogle Scholar
- 35.•• Simonsen CZ, Yoo AJ, Sørensen LH, Juul N, Johnsen SP, Andersen G, et al. Effect of general anesthesia and conscious sedation during endovascular therapy on infarct growth and clinical outcomes in acute ischemic stroke. JAMA Neurol. 2018;75:470–7. https://doi.org/10.1001/jamaneurol.2017.4474. Most recent randomized trial on anesthesia vs. outcome for ischemic stroke thrombectomy. CrossRefPubMedGoogle Scholar
- 36.• Rasmussen M, Espelund US, Juul N, Yoo AJ, Sørensen LH, Sørensen KE, et al. The influence of blood pressure management on neurological outcome in endovascular therapy for acute ischaemic stroke. Br J Anaesth. 2018; https://doi.org/10.1016/j.bja.2018.01.039. The first report examining the association of haemodynamic management on outcome in patients with acute ischaemic stroke undergoing EVT, using prospectively collected data from a randomised trial.
- 37.• Pfaff JAR, Schönenberger S, Nagel S, Ringleb PA, Hacke W, Bendszus M, et al. Effect of general anesthesia versus conscious sedation for stroke thrombectomy on angiographic workflow in a randomized trial: a post hoc analysis of the SIESTA trial. Radiology. 2017;286(3):1016–21. Study reporting shorter time to revascularization in the GA group during ischemic stroke thrombectomy. CrossRefPubMedGoogle Scholar
- 44.Whalin MK, Halenda KM, Haussen DC, Rebello LC, Frankel MR, Gershon RY, et al. Even small decreases in blood pressure during conscious sedation affect clinical outcome after stroke thrombectomy: an analysis of hemodynamic thresholds. Am J Neuroradiol. 2017;10(3174)Google Scholar
- 45.• Talke PO, Sharma D, Heyer EJ, Bergese SD, Blackham KA, Stevens RD. Republished: society for neuroscience in anesthesiology and critical care expert consensus statement: anesthetic management of endovascular treatment for acute ischemic stroke*. Stroke. 2014;45:138–51. Current recommendations on anesthesia for ischemic stroke thrombectomy. CrossRefGoogle Scholar
- 50.Futier E, Lefrant J-Y, Guinot P-G, Godet T, Lorne E, Cuvillon P, et al. Effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery. JAMA. 2017;318(14):1346–57.CrossRefPubMedPubMedCentralGoogle Scholar