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Anesthesia for Acute Ischemic Stroke: Updates and Ongoing Debates

  • Neuroanesthesia (D Sharma, Section Editor)
  • Published:
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Abstract

Purpose of Review

Advancements in stroke therapeutics and endovascular therapy in the last decade have dramatically changed the management of acute ischemic stroke, the structure of stroke care pathways, and demand for anesthesia resources. This review outlines the evolving perspectives on anesthetic management for the thrombectomy patient, including areas of debate, current recommendations, and future directions for research.

Recent Findings

Key concepts in stroke care include immediate medical attention, emergent transfer to a stroke facility, physiologic and hemodynamic stabilization, and rapid recanalization. Although optimal anesthetic technique is contested, there are evidence-based recommendations regarding physiologic and hemodynamic management on which the anesthesiologist can base their practice.

Summary

As anesthesiologists become more engaged in stroke care, lessons from this area can be used to understand other important questions of relevance to anesthesia. By investigating neurological outcomes related to physiologic management and anesthetic exposure, we can gain important information that can be applied to an aging population of perioperative patients.

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References

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  1. Johnson CO, Nguyen M, Roth GA, Nichols E, Alam T, Abate D, et al. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(5):439–58.

    Article  Google Scholar 

  2. •• Hindman BJ. Anesthetic management of emergency endovascular thrombectomy for acute ischemic stroke, Part 1: Patient characteristics, determinants of effectiveness, and effect of blood pressure on outcome. Anesth Analg. 2019;128(4):695–705 Part 1 of an extensive narrative review on the anesthetic management of EVT.

    Article  PubMed  Google Scholar 

  3. •• Businger J, Fort AC, Vlisides PE, Cobas M, Akca O. Management of acute ischemic stroke-specific focus on anesthetic management for mechanical thrombectomy. Anesth Analg. 2020;07:07 Detailed recent review of the management of acute ischemic stroke, with a focus on anesthesia for EVT.

    Google Scholar 

  4. Rodrigues FB, Neves JB, Caldeira D, Ferro JM, Ferreira JJ, Costa J. Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis. BMJ. 2016;353:i1754.

    Article  PubMed  PubMed Central  Google Scholar 

  5. •• Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–18 Landmark study demonstrating the superiority of EVT with standard care over standard care alone for patients with anterior circulation LVO.

    Article  CAS  PubMed  Google Scholar 

  6. •• Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30 Landmark study demonstrating the superiority of EVT with standard care over standard care alone for patients with anterior circulation LVO.

    Article  CAS  PubMed  Google Scholar 

  7. •• 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. 2014;372(1):11–20 Landmark study demonstrating the superiority of EVT with standard care over standard care alone for patients with anterior circulation LVO.

    Article  PubMed  CAS  Google Scholar 

  8. •• Saver JL, Goyal M, Bonafe A, Diener H-C, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285–95 Landmark study demonstrating the superiority of EVT with standard care over standard care alone for patients with anterior circulation LVO.

    Article  CAS  PubMed  Google Scholar 

  9. •• Jovin TG, Chamorro A, Cobo E, De Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296–306 Landmark study demonstrating the superiority of EVT with standard care over standard care alone for patients with anterior circulation LVO.

    Article  CAS  PubMed  Google Scholar 

  10. Goyal M, Menon BK, van Zwam WH, Dippel DW, 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(10029):1723–31.

    Article  PubMed  Google Scholar 

  11. • 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(8):708–18 Trial demonstrating that a 16 hour window for EVT is beneficial in patients with a relatively large penumbra compared to infarct core.

    Article  PubMed  PubMed Central  Google Scholar 

  12. • 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(1):11–21 Trial demonstrating that a 24 hour window for EVT is beneficial in patients with a relatively large penumbra compared to infarct core.

    Article  PubMed  Google Scholar 

  13. 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(8):2142–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Wijayatilake DS, Ratnayake G, Ragavan D. Anaesthesia for neuroradiology: thrombectomy: ‘one small step for man, one giant leap for anaesthesia’. Curr Opin Anaesthesiol. 2016;29(5):568–75.

    Article  CAS  PubMed  Google Scholar 

  15. Zhang Y, Jia L, Fang F, Ma L, Cai B, Faramand A. General anesthesia versus conscious sedation for intracranial mechanical thrombectomy: a systematic review and meta-analysis of randomized clinical trials. J Am Heart Assoc. 2019;8(12):e011754.

    Article  PubMed  PubMed Central  Google Scholar 

  16. 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. AJNR Am J Neuroradiol. 2015;36(3):525–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. 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(1):47–53.

    Article  PubMed  Google Scholar 

  18. 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.

    Article  PubMed  Google Scholar 

  19. Löwhagen Hendén P, Rentzos A, Karlsson JE, Rosengren L, Leiram B, Sundeman H, et al. General anesthesia versus conscious sedation for endovascular treatment of acute ischemic stroke: the AnStroke trial (Anesthesia During Stroke). Stroke. 2017;48(6):1601–7.

    Article  PubMed  CAS  Google Scholar 

  20. Simonsen CZ, Yoo AJ, Sorensen 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: a randomized clinical trial. JAMA Neurol. 2018;75(4):470–7.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Schonenberger S, Henden PL, Simonsen CZ, Uhlmann L, Klose C, Pfaff JAR, et al. Association of general anesthesia vs procedural sedation with functional outcome among patients with acute ischemic stroke undergoing thrombectomy: a systematic review and meta-analysis. JAMA. 2019;322(13):1283–93.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Campbell D, Diprose WK, Deng C, Barber PA. General anesthesia versus conscious sedation in endovascular thrombectomy for stroke: a meta-analysis of 4 randomized controlled trials. J Neurosurg Anesthesiol. 2019;26:26.

    Google Scholar 

  23. • Goyal N, Malhotra K, Ishfaq MF, Tsivgoulis G, Nickele C, Hoit D, et al. Current evidence for anesthesia management during endovascular stroke therapy: updated systematic review and meta-analysis. J Neurointerv Surg. 2019;11(2):107–13 Meta-analysis comparing GA to MAC for EVT demonstrating that GA was associated with lower odds of good functional outcome, except when analysis was limited to RCT data.

    Article  PubMed  Google Scholar 

  24. • Brinjikji W, Pasternak J, Murad MH, Cloft HJ, Welch TL, Kallmes DF, et al. Anesthesia-related outcomes for endovascular stroke revascularization: a systematic review and meta-analysis. Stroke. 2017;48(10):2784–91 Meta-analysis comparing GA to MAC for EVT demonstrating that GA was associated with lower odds of good functional outcome, except when analysis was limited to RCT data.

    Article  PubMed  Google Scholar 

  25. •• Hindman BJ, Dexter F. Anesthetic management of emergency endovascular thrombectomy for acute ischemic stroke, Part 2: Integrating and applying observational reports and randomized clinical trials. Anesth Analg. 2019;128(4):706–17 Part 2 of an extensive narrative review on the anesthetic management of EVT.

    Article  PubMed  Google Scholar 

  26. 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. AJNR Am J Neuroradiol. 2017;38(2):294–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Rasmussen M, Schönenberger S, Hendèn PL, Valentin JB, Espelund US, Sørensen LH, et al. Blood pressure thresholds and neurologic outcomes after endovascular therapy for acute ischemic stroke: an analysis of individual patient data from 3 randomized clinical trials. JAMA Neurol. 2020;77(5):622–31.

    Article  PubMed  Google Scholar 

  28. Chabanne R, Begard M, Cazenave L, Pereira B. New paradigm shift in perioperative medicine: general anaesthesia finally better than procedural sedation for anterior circulation stroke thrombectomy? Anaesth Crit Care Pain Med. 2019;38(6):585–7.

    Article  PubMed  Google Scholar 

  29. Goldhoorn RB, Bernsen MLE, Hofmeijer J, Martens JM, Lingsma HF, Dippel DWJ, et al. Anesthetic management during endovascular treatment of acute ischemic stroke in the MR CLEAN Registry. Neurology. 2020;94(1):e97–e106.

    Article  PubMed  Google Scholar 

  30. van de Graaf RA, Samuels N, Mulder M, Eralp I, van Es A, Dippel DWJ, et al. Conscious sedation or local anesthesia during endovascular treatment for acute ischemic stroke. Neurology. 2018;91(1):e19–25.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Pop R, Severac F, Happi Ngankou E, Harsan O, Martin I, Mihoc D, et al. Local anesthesia versus general anesthesia during endovascular therapy for acute stroke: a propensity score analysis. J Neurointerv Surg. 2020;02:02.

    Google Scholar 

  32. Benvegnu F, Richard S, Marnat G, Bourcier R, Labreuche J, Anadani M, et al. Local anesthesia without sedation during thrombectomy for anterior circulation stroke is associated with worse outcome. Stroke. 2020;51(10):2951–9.

    Article  CAS  PubMed  Google Scholar 

  33. Parthasarathy R, Gupta V. Mechanical thrombectomy: answering unanswered. Ann Indian Acad Nuerol. 2020;23(1):13–9.

    Google Scholar 

  34. •• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–418 Most up-to-date guidelines for management of acute ischemic stroke, including a statement on anesthetic management.

    Article  PubMed  Google Scholar 

  35. •• 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(8):e138–50 Consensus guidelines from an international expert panel which include detailed recommendations for anesthetic management of EVT.

    Article  CAS  PubMed  Google Scholar 

  36. McTaggart RA, Ansari SA, Goyal M, Abruzzo TA, Albani B, Arthur AJ, et al. Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery. J Neurointerv Surg. 2017;9(3):316–23.

    Article  PubMed  Google Scholar 

  37. Fröhlich K, Macha K, Gerner ST, Bobinger T, Schmidt M, Dörfler A, et al. Angioedema in stroke patients with thrombolysis. Stroke. 2019;50(7):1682–7.

    Article  PubMed  Google Scholar 

  38. 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(2):396–405.

    Article  CAS  PubMed  Google Scholar 

  39. Akca O, Nichols J, Stewart B, Elliott C, Remmel K, Lenhardt R. Association of early oxygenation levels with mortality in acute ischemic stroke - a retrospective cohort study. J Stroke Cerebrovasc Dis. 2020;29(2):104556.

    Article  PubMed  Google Scholar 

  40. Petersen NH, Ortega-Gutierrez S, Wang A, Lopez GV, Strander S, Kodali S, et al. Decreases in blood pressure during thrombectomy are associated with larger infarct volumes and worse functional outcome. Stroke. 2019;50(7):1797–804.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Roffe C, Nevatte T, Sim J, Bishop J, Ives N, Ferdinand P, et al. Effect of routine low-dose oxygen supplementation on death and disability in adults with acute stroke. JAMA. 2017;318(12):1125.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Mundiyanapurath S, Stehr A, Wolf M, Kieser M, Mohlenbruch M, Bendszus M, et al. Pulmonary and circulatory parameter guided anesthesia in patients with ischemic stroke undergoing endovascular recanalization. J Neurointerv Surg. 2016;8(4):335–41.

    Article  CAS  PubMed  Google Scholar 

  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(2):202–8.

    Article  CAS  PubMed  Google Scholar 

  44. 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. 2018;30(3):223–30.

    Article  PubMed  Google Scholar 

  45. Chabanne R, Fernandez-Canal C, Degos V, Lukaszewicz AC, Velly L, Mrozek S, et al. Sedation versus general anaesthesia in endovascular therapy for anterior circulation acute ischaemic stroke: the multicentre randomised controlled AMETIS trial study protocol. BMJ Open. 2019;9(9):e027561.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Van Der Hoeven EJ, Schonewille WJ, Vos J, Algra A, Audebert HJ, Berge E, et al. The Basilar Artery International Cooperation Study (BASICS): study protocol for a randomised controlled trial. Trials. 2013;14(1):200.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Liu X, Xu G, Liu Y, Zhu W, Ma M, Xiong Y, et al. Acute basilar artery occlusion: Endovascular Interventions versus Standard Medical Treatment (BEST) Trial-Design and protocol for a randomized, controlled, multicenter study. Int J Stroke. 2017;12(7):779–85.

    Article  PubMed  Google Scholar 

  48. Yang P, Zhang Y, Zhang L, Zhang Y, Treurniet KM, Chen W, et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med. 2020;382(21):1981–93.

    Article  CAS  PubMed  Google Scholar 

  49. Campbell BCV, Mitchell PJ, Churilov L, Yassi N, Kleinig TJ, Dowling RJ, et al. Tenecteplase versus alteplase before thrombectomy for ischemic Stroke. N Engl J Med. 2018;378(17):1573–82.

    Article  CAS  PubMed  Google Scholar 

  50. Sun J, Liang F, Wu Y, Zhao Y, Miao Z, Zhang L, et al. Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic Stroke (CANVAS): results of the CANVAS pilot randomized controlled trial. J Neurosurg Anesthesiol. 2020;32(1):41–7.

    Article  PubMed  Google Scholar 

  51. Diprose WK, Wang MTM, Campbell D, Sutcliffe JA, McFetridge A, Chiou D, et al. Intravenous propofol versus volatile anesthetics for stroke endovascular thrombectomy. J Neurosurg Anesthesiol. 2019;23:23.

    Google Scholar 

  52. 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(11):1101–6.

    Article  PubMed  Google Scholar 

  53. Bell JD. In Vogue: ketamine for neuroprotection in acute neurologic injury. Anesth Analg. 2017;124(4):1237–43.

    Article  CAS  PubMed  Google Scholar 

  54. Deng C, Campbell D, Diprose W, Eom C, Wang K, Robertson N, et al. A pilot randomised controlled trial of the management of systolic blood pressure during endovascular thrombectomy for acute ischaemic stroke. Anaesthesia. 2020;75(6):739–46.

    Article  CAS  PubMed  Google Scholar 

  55. Venema AM, Uyttenboogaart M, Absalom AR. Land of confusion: anaesthetic management during thrombectomy for acute ischaemic stroke. Br J Anaesth. 2019;122(3):300–4.

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors would like to thank Nicole Dunnewold from the Health Sciences Library, University of Calgary, for her support in the development of a search strategy for this narrative review.

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Authors and Affiliations

  1. Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Foothills Medical Centre, C222, 1403-29 St NW, Calgary, AB, T2N 2T9, Canada

    Lauren Crosby

  2. Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Hotchkiss Brain Institute, C222, 1403-29 St NW, Calgary, AB, T2N 2T9, Canada

    Melinda Davis

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Correspondence to Melinda Davis.

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Crosby, L., Davis, M. Anesthesia for Acute Ischemic Stroke: Updates and Ongoing Debates. Curr Anesthesiol Rep 11, 147–157 (2021). https://doi.org/10.1007/s40140-021-00447-4

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