Current Anesthesiology Reports

, Volume 8, Issue 3, pp 270–278 | Cite as

Anaesthesia for Endovascular Treatment of Acute Ischemic Stroke: Still Controversial?

  • Line K. Rasmussen
  • Claus Z. Simonsen
  • Pia Löwhagen Hendén
  • Julian Bösel
  • Mads RasmussenEmail author
Neuroanesthesia (D Sharma, Section Editor)
Part of the following topical collections:
  1. Neuroanesthesia


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.

Recent Findings

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.


Anaesthesia 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

  1. 1.
    Go A, Mozaffarian D, Roger V. Circulation EB-, 2014 undefined. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28–e292.CrossRefPubMedGoogle Scholar
  2. 2.
    Goyal M, Menon BK, van Zwam WH, Dippel DWJ, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–31.CrossRefPubMedGoogle Scholar
  3. 3.
    • Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378:708–18. Study demonstrating that EVT is effective up til 16 h from stroke onset. CrossRefPubMedGoogle Scholar
  4. 4.
    • Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378:11–21. Study demonstrating that EVT is effective up til 24 h from stroke onset. CrossRefPubMedGoogle Scholar
  5. 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. 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. 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; Recent study suggesting influence of ventilation on outcome after ischemic stroke thrombectomy.
  8. 8.
    Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CBLM, Dippel DW, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316(12):1279–88.CrossRefPubMedGoogle Scholar
  9. 9.
    McDonagh DL, Olson DM, Kalia JS, Gupta R, Abou-Chebl A, Zaidat OO. Anesthesia and sedation practices among neurointerventionalists during acute ischemic stroke endovascular therapy. Front Neurol. 2010;1:118.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Rasmussen M, Simonsen CZ, Sørensen LH, Dyrskog S, Rusy DA, Sharma D, et al. Anaesthesia practices for endovascular therapy of acute ischaemic stroke: a Nordic survey. Acta Anaesthesiol Scand. 2017;61(8):885–94.CrossRefPubMedGoogle Scholar
  11. 11.
    • Anastasian ZH. Anaesthetic management of the patient with acute ischaemic stroke. Br J Anaesth. 2014;113:ii9–ii16. Comprehensive review of anesthesia for stroke revascularization. CrossRefPubMedGoogle Scholar
  12. 12.
    McDonald JS, Brinjikji W, Rabinstein AA, Cloft HJ, Lanzino G, Kallmes DF. Conscious sedation versus general anaesthesia during mechanical thrombectomy for stroke: a propensity score analysis. J Neurointerv Surg. 2015;7:789–94.CrossRefPubMedGoogle Scholar
  13. 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. 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
  15. 15.
    Nichols C, Carrozzella J, Yeatts S, Tomsick T, Broderick J, Khatri P. Is periprocedural sedation during acute stroke therapy associated with poorer functional outcomes? J Neurointerv Surg. 2010;2(1):67–70.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 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
  17. 17.
    Hassan AE, Chaudhry SA, Zacharatos H, Khatri R, Akbar U, Suri MFK, et al. Increased rate of aspiration pneumonia and poor discharge outcome among acute ischemic stroke patients following intubation for endovascular treatment. Neurocrit Care. 2012;16:246–50.CrossRefPubMedGoogle Scholar
  18. 18.
    Li F, Deshaies EM, Singla A, Villwock MR, Melnyk V, Gorji R, et al. Impact of anesthesia on mortality during endovascular clot removal for acute ischemic stroke. J Neurosurg Anesthesiol. 2014;26:286–90.CrossRefPubMedGoogle Scholar
  19. 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
  20. 20.
    Abou-Chebl A, Yeatts SD, Yan B, Cockroft K, Goyal M, Jovin T, et al. Impact of general anesthesia on safety and outcomes in the endovascular arm of interventional management of stroke (IMS) III trial. Stroke. 2015;46:2142–8.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    van den Berg LA, Koelman DLHH, Berkhemer OA, Rozeman AD, Fransen PSSS, Beumer D, et al. Type of anesthesia and differences in clinical outcome after intra-arterial treatment for ischemic stroke. Stroke. 2015;46:1257–62.CrossRefPubMedGoogle Scholar
  22. 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
  23. 23.
    Abou-Chebl A, Zaidat O, Castonguay A, Stroke RG. North American SOLITAIRE stent-retriever acute stroke registry: choice of anesthesia and outcomes. Stroke. 2014;45:1396–401.CrossRefPubMedGoogle Scholar
  24. 24.
    • Bekelis K, Missios S, MacKenzie TA, Tjoumakaris S, Jabbour P. Anesthesia technique and outcomes of mechanical thrombectomy in patients with acute ischemic stroke. Stroke. 2017;48:361–6. Largest retrospective analysis of anesthesia vs. outcome. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    John S, Thebo U, Saqqur M, Gomes J, Farag E, Hussain MS, et al. Intra-arterial therapy for acute ischemic stroke under general anesthesia versus monitored anesthesia care. Cerebrovasc Dis. 2014;38(4):262–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Jagani M, Brinjikji W, Rabinstein AA, Pasternak JJ, Kallmes DF. Hemodynamics during anesthesia for intra-arterial therapy of acute ischemic stroke. J Neurointerv Surg. 2016;8:883–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Just C, Rizek P, Tryphonopoulos P, Pelz D, Arango M. Outcomes of general anesthesia and conscious sedation in endovascular treatment for stroke. Can J Neurol Sci. 2016;43:655–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Brinjikji W, Pasternak J, Murad MH, Cloft HJ, Welch TL, Kallmes DF, et al. Anesthesia-related outcomes for endovascular stroke revascularization. Stroke. 2017;48:2784–91.CrossRefPubMedGoogle Scholar
  29. 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
  30. 30.
    Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20.CrossRefPubMedGoogle Scholar
  31. 31.
    Treurniet KM, Berkhemer OA, Immink RV, Lingsma HF, Ward-van der Stam VMC, Hollmann MW, et al. A decrease in blood pressure is associated with unfavorable outcome in patients undergoing thrombectomy under general anesthesia. J NeuroIntervent Surg. 2018;10(2):107–11.CrossRefGoogle Scholar
  32. 32.
    • Dinsmore J. HERMES: a helpful messenger in the anaesthesia for thrombectomy debate? Lancet Neurol. 2018;17:21–3. Thoughtful commentary discussing the pitfalls and limitations of the HERMES analysis on anesthesia for thrombectomy. CrossRefPubMedGoogle Scholar
  33. 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. 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. 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. Most recent randomized trial on anesthesia vs. outcome for ischemic stroke thrombectomy. CrossRefPubMedGoogle Scholar
  36. 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; 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. 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
  38. 38.
    Britton M, Carlsson A, de Faire U. Blood pressure course in patients with acute stroke and matched controls. Stroke. 1986;17(5):861–4.CrossRefPubMedGoogle Scholar
  39. 39.
    Harper G, Fotherby MD, Panayiotou BJ, Castleden CM, Potter JF. The changes in blood pressure after acute stroke: abolishing the “white coat effect” with 24-h ambulatory monitoring. J Intern Med. 1994;235:343–6.CrossRefPubMedGoogle Scholar
  40. 40.
    Alqadri SL, Sreenivasan V, Qureshi AI. Acute hypertensive response management in patients with acute stroke. Curr Cardiol Rep. 2013;15:426.CrossRefPubMedGoogle Scholar
  41. 41.
    Qureshi A, Ezzeddine M, Nasar A, Suri MF, Kirmani JF, Hussein HM, et al. Prevalence of elevated blood pressure in 563704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007;25(1):32–8.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Leonardi-Bee J, Bath PMW, Phillips SJ, Sandercock PAG. Blood pressure and clinical outcomes in the international stroke trial. Stroke. 2002;33:1315–20.CrossRefPubMedGoogle Scholar
  43. 43.
    Takahashi CE, Brambrink AM, Aziz MF, Macri E, Raines J, Multani-Kohol A, et al. Association of intraprocedural blood pressure and end tidal carbon dioxide with outcome after acute stroke intervention. Neurocrit Care. 2014;20:202–8.CrossRefPubMedGoogle Scholar
  44. 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. 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
  46. 46.
    Østergaard L, Jespersen SN, Mouridsen K, Mikkelsen IK, Jonsdottír KÝ, Tietze A, et al. The role of the cerebral capillaries in acute ischemic stroke: the extended penumbra model. J Cereb Blood Flow Metab. 2013;33:635–48.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Maeda H, Matsumoto M, Handa N, Hougaku H, Ogawa S, Itoh T, et al. Reactivity of cerebral blood flow to carbon dioxide in various types of ischemic cerebrovascular disease: evaluation by the transcranial Doppler method. Stroke. 1993;24:670–5.CrossRefPubMedGoogle Scholar
  48. 48.
    Badenes R, Gruenbaum SE, Bilotta F. Cerebral protection during neurosurgery and stroke. Curr Opin Anaesthesiol. 2015;28:532–6.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Sivasankar C, Stiefel M, Miano TA, Kositratna G, Yandrawatthana S, Hurst R, et al. Anesthetic variation and potential impact of anesthetics used during endovascular management of acute ischemic stroke. J Neurointerv Surg. 2016;8:1101–6.CrossRefPubMedGoogle Scholar
  50. 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

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Line K. Rasmussen
    • 1
  • Claus Z. Simonsen
    • 2
  • Pia Löwhagen Hendén
    • 3
  • Julian Bösel
    • 4
    • 5
  • Mads Rasmussen
    • 1
    Email author
  1. 1.Department of Anesthesia and Intensive Care, Section of NeuroanesthesiaAarhus University HospitalAarhus CDenmark
  2. 2.Department of NeurologyAarhus University HospitalAarhusDenmark
  3. 3.Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, Sahlgrenska University HospitalUniversity of GothenburgGothenburgSweden
  4. 4.Department of NeurologyKassel General HospitalKasselGermany
  5. 5.Department of NeurologyUniversity Hospital HeidelbergHeidelbergGermany

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