Hypotension during endovascular treatment under general anesthesia for acute ischemic stroke

Arterial hypotension "magnitude" and neurological outcome during mechanical thrombectomy under general anesthesia

INTRODUCTION

Mechanical thrombectomy (MT) is the standard of care for the treatment of acute ischemic stroke (AIS) with large vessel occlusion (LVO), but unfavorable outcomes remain common. Procedural arterial hypotension is associated with poor patient outcome. This study aimed to assess the impact of arterial hypotension "magnitude" (a combination of the depth, defined as the percentage relative to baseline arterial blood pressure, and the duration of hypotensive episodes)" during MT on neurological outcome.

METHODS

This is a monocentric retrospective study. Charts were reviewed between January 2018 and June 2021. "Patients were eligible if they were 18 years or older, anterior LVO was diagnosed on cerebral imaging" and MT performed under general anesthesia. Mean arterial pressure (MAP) was recorded every 5 min throughout the procedure, and the arterial hypotension "magnitude" was estimated by the area under the curve (AUC) for different thresholds of MAP drops.

MAIN OUTCOME MEASURE

The modified Rankin Scale (mRS) at 90 days.

MAIN RESULTS

Among the 117 patients analyzed, 46% had poor neurological outcome. Our study showed correlations between poor outcome and a greater procedural AUC of arterial hypotension for the different thresholds: 5% (k 0.18; 95% CI 0.06-0.30; P = 0.007), 10% (k 0.18; 95% CI 0.05-0.30; P = 0.008), 15% (k 0.18; 95% CI 0.04-0.30; P = 0.011), 20% (k 0.18; 95% CI 0.05-0.30; P = 0.010) and 30% (k 0.19; 95% CI 0.05-0.31; P = 0.010). This association persisted after controlling for age, baseline NIHSS score, and ASPECT score.

CONCLUSION

The magnitude of hypotension during MT under general anesthesia for AIS is an independent factor of poor outcome at 90 days. These associations have been observed in patients with mild and severe hypotensive episodes.

Minimum-incision transsubclavian transcatheter aortic valve replacement with balloon-expandable valve for dialysis patients

BACKGROUND

Dialysis patients undergoing transcatheter aortic valve replacement (TAVR) face increased risk and have poorer outcomes than non-dialysis patients. Moreover, TAVR in dialysis patients using an alternative approach is considered extremely risky and little is known about the outcomes. We routinely perform minimum-incision transsubclavian TAVR (MITS-TAVR), which is contraindicated for transfemoral (TF) TAVR. This study aimed to evaluate the outcomes of MITS-TAVR compared with those of TF-TAVR in dialysis patients.

METHODS

This single-center, observational study included 79 consecutive dialysis patients who underwent MITS-TAVR (MITS group, n = 22) or TF-TAVR (TF group, n = 57) under regional anesthesia.

RESULTS

The rates of peripheral artery disease (MITS vs. TF, 72.7 % vs. 26.3 %; p < 0.01), shaggy aortas (MITS vs. TF, 63.6 % vs. 5.26 %; p < 0.01), and tortuous aortas (MITS vs. TF, 13.6 % vs. 1.75 %; p = 0.031) were significantly higher in the MITS group. The 30-day mortality was 2.53 % and comparable between the two groups (MITS vs. TF, 4.54 % vs. 1.75 %; p = 0.479). In the MITS group, 14 patients had ipsilateral dialysis fistulas, and three patients had patent in situ ipsilateral internal thoracic artery grafts; however, no vascular complications were observed. Kaplan-Meier survival curves for the two groups showed no significant difference in the survival rate (at 2 years; MITS vs. TF, 77.3 % vs. 68.8 %; p = 0.840) and freedom from cardiovascular mortality (at 2 years; MITS vs. TF, 90.9 % vs. 96.5 %; p = 0.898). The multivariable Cox proportional hazard model also indicated that survival in the MITS group was not significantly different from that in the TF group (hazard ratio 1.48; 95 % confidence interval, 0.77-2.85, p = 0.244). The patency rate of ipsilateral dialysis fistula was 100 % during follow-up.

CONCLUSION

The outcome of MITS-TAVR was comparable to that of TF-TAVR in dialysis patients, despite the higher risk of patient characteristics.

Continuous non-invasive vs. invasive arterial blood pressure monitoring during neuroradiological procedure: a comparative, prospective, monocentric, observational study

BACKGROUND

In the perioperative setting, the most accurate way to continuously measure arterial blood pressure (ABP) is using an arterial catheter. Surrogate methods such as finger cuff have been developed to allow non-invasive measurements and are increasingly used, but need further evaluation. The aim of this study is to evaluate the accuracy and clinical concordance between two devices for the measurement of ABP during neuroradiological procedure.

METHODS

This is a prospective, monocentric, observational study. All consecutive patients undergoing a neuroradiological procedure were eligible. Patients who needed arterial catheter for blood pressure measurement were included. During neuroradiological procedure, ABP (systolic, mean and diatolic blood pressure) was measured with two different technologies: radial artery catheter and Nexfin. Bland-Altman and error grid analyses were performed to evaluate the accuracy and clinical concordance between devices.

RESULTS

From March 2022 to November 2022, we included 50 patients, mostly ASA 3 (60%) and required a cerebral embolization (94%) under general anaesthesia (96%). Error grid analysis showed that 99% of non-invasive ABP measures obtained with the Nexfin were located in the risk zone A or B. However, 65.7% of hypertension events and 41% of hypotensive events were respectively not detected by Nexfin. Compared to the artery catheter, a significant relationship was found for SAP (r2 = 0.78) and MAP (r2 = 0.80) with the Nexfin (p < 0.001). Bias and limits of agreement (LOA) were respectively 9.6 mmHg (- 15.6 to 34.8 mmHg) and - 0.8 mmHg (- 17.2 to 15.6 mmHg), for SAP and MAP.

CONCLUSIONS

Nexfin is not strictly interchangeable with artery catheter for ABP measuring. Further studies are needed to define its clinical use during neuroradiological procedure.

TRIAL REGISTRATION

Clinicaltrials.gov, registration number: NCT05283824.

Demonstrating the Value of Routine Anesthesiologist Involvement in Acute Stroke Care: A Retrospective Chart Review

INTRODUCTION

The value of routine involvement of anesthesiologists during endovascular thrombectomy (EVT) for acute ischemic stroke has not been clearly demonstrated. At some institutions, anesthesiologists are involved only as needed, while at other institutions, anesthesiologists are involved from the beginning for every EVT.

METHODS

We retrospectively analyzed the workflow, intraprocedural variables and complications, and outcomes in acute ischemic stroke patients undergoing EVT at a comprehensive stroke center after implementation of routine involvement of an anesthesia team and compared this cohort with patients who received care from sedation-trained nurses working under the supervision of neurointerventionalists with the involvement of anesthesiologists on an as-needed basis.

RESULTS

Routine involvement of anesthesiologists was associated with improved workflow performance measures, including decreased median door-to-arterial puncture time (68 min; interquartile range (IQR), 15.5-94.5 min vs. 81 min; IQR, 53-104 min; P =0.001), in-room to arterial puncture time (11 min; IQR, 8-14 min vs. 15 min; IQR, 9-21 min; P <0.0001), and procedure time (51 min; IQR, 40-64 min vs. 60 min; IQR, 40-88.5 min; P =0.007). It was also associated with a nonsignificant trend towards lower rates of desaturation events (8.2% vs. 3.4%; P =0.082) and lower rates of conversion to general anesthesia (1.7% vs. 0%; P =0.160). Ninety-day modified Rankin scores were similar regardless of provider type.

CONCLUSION

Implementation of routine involvement of an anesthesia team during EVT was not associated with improved outcomes but was associated with improved efficiency and greater adherence to guidelines-based physiological parameters, supporting the routine involvement of anesthesiologists during EVT.

Risk factors for stroke recurrence in young patients with first-ever ischemic stroke: A meta-analysis

BACKGROUND

At present, the incidence rate of ischemic stroke in young people is increasing yearly, and the age of onset is increasingly young. Therefore, primary and secondary prevention of ischemic stroke in young people, especially secondary prevention, is particularly crucial.

AIM

We aimed to comprehensively evaluate risk factors for stroke recurrence in first-ever young ischemic stroke (YIS) patients.

METHODS

The meta-analysis was used to quantitatively analyze the research results on risk factors for stroke recurrence in first-ever YIS patients both domestically and internationally. Stata12.0 software was used for heterogeneity testing, publication bias analysis, sensitivity analysis, and the calculation of combined odds ratios and 95% confidence intervals.

RESULTS

The odds ratio (OR) values of the relationship between hypertension and hyperlipidemia and recurrence of first-ever YIS were 1.54 (1.05-2.26) and 1.12 (1.00-1.25), respectively. The OR values of male sex, type 2 diabetes, smoking, drinking and YIS recurrence were 1.66 (0.98-2.79), 1.01 (0.64-1.59), 1.21 (0.83-1.76), and 1.28 (0.82-2.53), respectively. The relationship between male sex, type 2 diabetes, smoking, drinking and YIS recurrence was ambiguous.

CONCLUSION

Hypertension and hyperlipidemia are important risk factors for stroke recurrence in first-ever YIS patients, and active intervention should be taken.

Acute Ischemic Stroke in Pregnancy : A Practical Focus on Neuroimaging and Reperfusion Therapy

INTRODUCTION

Pregnancy increases the risk of acute ischemic stroke (AIS) among young women and is responsible for about 5% of maternal deaths and significant disability. Concerns of potential adverse events of imaging and reperfusion therapies in this group of patients can lead to a substantial delay or omission of treatment that can significantly worsen outcomes.

OBJECTIVE

The objective of this study is to discuss main concerns of diagnosis and therapy of pregnant patients with AIS regarding neuroimaging and reperfusion treatment.

RESULTS

The cumulative radiation dose of computed tomography (CT)-based entire diagnostic procedure (noncontrast CT, CT-angiography and CT-perfusion) is estimated to be below threshold for serious fetal radiation exposure adverse events. Similarly, magnetic resonance imaging(MRI)-based imaging is thought to be safe as long as gadolinium contrast media are avoided. The added risk of intravenous thrombolysis (IVT) and mechanical thrombectomy during pregnancy is thought to be very low. Nevertheless, some additional safety measures should be utilized to reduce the risk of radiation, contrast media and hypotension exposure during diagnostic procedures or reperfusion treatment.

CONCLUSION

Fetal safety concerns should not preclude routine diagnostic work-up (except for gadolinium contrast media administration) in childbearing AIS women, including procedures applied in unknown onset and late onset individuals. Due to rather low added risk of serious treatment complications, pregnancy should not be a sole contraindication for neither IVT, nor endovascular treatment.

Minimum-incision trans-subclavian transcatheter aortic valve replacement with regional anesthesia

BACKGROUND

Minimum-incision trans-subclavian transcatheter aortic valve replacement (MITS-TAVR) is usually performed in patients who are contraindicated for transfemoral TAVR, under regional anesthesia (RA). This study aimed to evaluate the safety and efficacy of MITS-TAVR under RA compared to MITS-TAVR under general anesthesia (GA).

METHODS

This single-center observational study included 44 consecutive patients who underwent MITS-TAVR under RA (RA group, n = 19) and GA (GA group, n = 25). RA was achieved using an ultrasound-guided nerve block.

RESULTS

The rates of respiratory disease (RA vs. GA, 36.8 % vs. 4.0 %; p < 0.01) and dialysis (79.0 % vs. 0 %; p < 0.01) were significantly higher in the RA group. STS score was significantly higher in the RA group (RA vs. GA, 10.8 ± 1.06 % vs. 7.87 ± 0.93 %; p < 0.01). Both groups had a 100 % procedural success rate. The two groups showed comparable operation room stay times (RA vs. GA, 160 ± 6.96 min vs. 148 ± 5.90 min; p = 0.058). The mean rate of change in blood pressure, used as an index of hemodynamic stability, was significantly lower in the RA group (RA vs. GA, 19.0 ± 3.4 % vs. 35.5 ± 3.0 %; p < 0.01). No in-hospital deaths occurred in either group. One case of minor dissection occurred in the GA group (RA vs.GA, 0 % vs. 4.0 %, p = 0.378). The intensive care unit stay (RA vs. GA, 0.21 ± 0.11 days vs. 1.24 ± 0.10 days; p < 0.01) and hospital stay (RA vs. GA, 7.00 ± 1.73 days vs. 12.2 ± 1.44 days; p < 0.01) were significantly shorter in the RA group.

CONCLUSIONS

MITS-TAVR under RA is safe and effective and might be a promising alternative approach. It could ensure intraoperative hemodynamic stability and shorten intensive care unit and hospital stays.

Near-infrared spectroscopy monitoring during endovascular treatment for acute ischaemic stroke

INTRODUCTION

The aim of endovascular treatment (EVT) for acute ischaemic stroke is to relieve the cerebral tissue hypoxia in the area supplied by the occluded artery. Near-infrared spectroscopy (NIRS) monitoring is developed to assess regional cerebral tissue oxygen haemoglobin saturation (rSO2). We aimed to investigate whether NIRS can detect inter- and intra-hemispheric rSO2 differences during EVT.

PATIENTS AND METHODS

In this prospective, observational study, patients undergoing EVT for a proximal intracranial occlusion of the anterior circulation between May 2019 and November 2020, were included. A four-wavelength NIRS monitor (O3® Regional Oximeter (Masimo, Irvine, CA)) was used to measure rSO2 during EVT with sensors placed over the temporal lobes in 20 patients and over the frontal lobes in 13 patients. The Wilcoxon signed-rank test was used to test for inter-hemispheric rSO2 differences after groin puncture and after recanalisation, and intra-hemispheric rSO2 changes before and after recanalisation.

RESULTS

In the temporal cohort, no inter-hemispheric rSO2 differences were observed after groin puncture (median [IQR] rSO2 affected hemisphere, 70% [67-73] and unaffected hemisphere, 70% [66-72]; p = 0.79) and after recanalisation. There were no intra-hemispheric rSO2 changes over time. In the frontal cohort, no inter- and intra-hemispheric rSO2 differences or changes were found.

DISCUSSION AND CONCLUSION

A NIRS monitor could not detect inter- and intra-hemispheric rSO2 differences or changes during EVT, irrespective of the sensor position. It is likely that even with temporal sensor application, a significant proportion of the received NIRS signal was influenced by oxygenation of surrounding tissues.

General anesthesia but not conscious sedation improves functional outcome in patients receiving endovascular thrombectomy for acute ischemic stroke: A meta-analysis of randomized clinical trials and trial sequence analysis

Background

This study aimed at comparing the difference in prognostic outcomes between patients receiving general anesthesia (GA) and conscious sedation (CS) for endovascular thrombectomy after acute ischemic stroke.

Methods

Databases from Medline, Embase, Google scholar, and Cochrane library were searched for randomized controlled studies (RCTs) comparing patients undergoing GA and CS for endovascular thrombectomy following anterior circulation ischemic stroke. The primary outcome was frequency of 90-day good functional outcome [defined as modified Rankin Scale score of ≤ 2], while secondary outcomes included successful recanalization rate (SRR) [i.e., modified thrombolysis in cerebral infarction = 2b or 3], mortality risk, symptomatic intracranial hemorrhage (ICH), procedure-related complications, hypotension, pneumonia, neurological outcome at post-procedure 24–48 h, and puncture-to-recanalization time.

Results

Six RCTs including 883 patients published between 2016 and 2022 were included. Merged results revealed a higher SRR [risk ratio (RR) = 1.11, 95% CI: 1.03–1.2, p = 0.007; I² = 29%] and favorable neurological outcomes at 3-months (RR = 1.2, 95% CI: 1.01–1.41, p = 0.04; I² = 8%) in the GA group compared to CS group, without difference in the risk of mortality (RR = 0.88), symptomatic ICH (RR = 0.91), procedure-related complications (RR = 1.05), and pneumonia (RR = 1.9) as well as post-procedure neurological outcome (MD = −0.21) and successful recanalization time (MD = 3.33 min). However, GA was associated with a higher risk of hypotension compared with that of CS.

Conclusion

Patients with acute anterior circulation ischemic stroke receiving GA were associated with a higher successful recanalization rate as well as a better 3-month neurological outcome compared to the use of CS. Further investigations are warranted to verify our findings.

Systematic review registration

www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022342483, identifier: CRD42022342483.

Anesthetic considerations for endovascular treatment in stroke therapy

PURPOSE OF REVIEW

The introduction of clot removement by endovascular treatment (EVT) in 2015 has improved the clinical outcome of patients with acute ischemic stroke (AIS) due to a large vessel occlusion (LVO). Anesthetic strategies during EVT vary widely between hospitals, with some departments employing local anesthesia (LA), others performing conscious sedation (CS) or general anesthesia (GA). The optimal anesthetic strategy remains debated. This review will describe the effects of anesthetic strategy on clinical and radiological outcomes and hemodynamic parameters in patients with AIS undergoing EVT.

RECENT FINDINGS

Small single-center randomized controlled trails (RCTs) found either no difference or favored GA, while large observational cohort studies favored CS or LA. RCTs using LA as separate comparator arm are still lacking and a meta-analysis of observational studies failed to show differences in functional outcome between LA vs. other anesthetic strategies. Advantages of LA were shorter door-to-groin time in patients and less intraprocedural hypotension, which are both variables that are known to impact functional outcome.

SUMMARY

The optimal anesthetic approach in patients undergoing EVT for stroke therapy is still unclear, but based on logistics and peri-procedural hemodynamics, LA may be the optimal choice. Multicenter RCTs are warranted comparing LA, CS and GS with strict blood pressure targets and use of the same anesthetic agents to minimize confounding variables.