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Is General Anesthesia for Endovascular Thrombectomy Helpful or Harmful? Can J Neurol Sci 2021; 49:746-760. [PMID: 34511142 DOI: 10.1017/cjn.2021.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endovascular thrombectomy (EVT) has significantly improved outcomes for patients with acute ischemic stroke due to large vessel occlusion. However, despite advances, more than half of patients remain functionally dependent 3 months after their initial stroke. Anesthetic strategy may influence both the technical success of the procedure and overall outcomes. Conventionally, general anesthesia (GA) has been widely used for neuroendovascular procedures, particularly for the distal intracranial circulation, because the complete absence of movement has been considered imperative for procedural success and to minimize complications. In contrast, in patients with acute stroke undergoing EVT, the optimal anesthetic strategy is controversial. Nonrandomized studies suggest GA negatively affects outcomes while the more recent anesthesia-specific RCTs report improved or unchanged outcomes in patients managed with versus without GA, although these findings cannot be generalized to other EVT capable centers due to a number of limitations. Potential explanations for these contrasting results will be addressed in this review including the effect of different anesthetic strategies on cerebral and systemic hemodynamics, revascularization times, and periprocedural complications.
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Does General Anesthesia Compared With Conscious Sedation Result in Better Outcomes in Acute Stroke Patients Undergoing Endovascular Therapy? Neurologist 2021; 26:47-51. [PMID: 33646989 DOI: 10.1097/nrl.0000000000000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is considerable controversy surrounding the optimal use of sedation in patients with acute ischemic stroke undergoing mechanical thrombectomy. Several retrospective studies have favored conscious sedation (CS) over general anesthesia (GA) in terms of functional outcomes and mortality. Recent data from randomized controlled trials has challenged this view. OBJECTIVE The aim was to critically assess current evidence regarding the use of CS versus GA in mechanical thrombectomy for acute ischemic stroke. METHODS The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular neurology, vascular neurosurgery, and interventional neuroradiology. RESULTS A randomized controlled trial was selected for critical appraisal. This trial compared 128 patients with acute ischemic stroke and large vessel occlusion from a single center (Aarhus University Hospital, Denmark), 65 of whom received GA and 63 received CS. No significant difference was detected for the primary outcome of volume of infarct growth. The rate of successful thrombectomy and favorable clinical outcomes for the GA arm was significantly higher in the intention-to-treat analysis. CONCLUSIONS GA does not result in worse tissue outcomes or worse clinical outcomes when compared with CS in acute stroke patients with large vessel occlusion undergoing mechanical thrombectomy.
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Abstract
Anesthesiologists provide care to acute and subacute ischemic stroke (IS) patients and stroke survivors in interventional radiology, intensive care, and operating rooms. These encounters will become more frequent following studies that have extended the treatment window from last known well time for fibrinolytic and endovascular thrombectomy (EVT). The number of stroke centers certified to quickly and effectively initiate treatment of IS patients and the number of patients connected to them by telehealth continue to grow. This article reviews IS pathophysiology, assessment, treatment, pathology, and complications; anesthetic management during EVT; perioperative stroke management; and how anesthesia has an impact on patients with prior stroke.
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Liang F, Zhao Y, Yan X, Wu Y, Li X, Zhou Y, Jian M, Li S, Miao Z, Han R, Peng Y. Choice of ANaesthesia for EndoVAScular treatment of acute ischaemic stroke at posterior circulation (CANVAS II): protocol for an exploratory randomised controlled study. BMJ Open 2020; 10:e036358. [PMID: 32737091 PMCID: PMC7398089 DOI: 10.1136/bmjopen-2019-036358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Observational and interventional studies indicate that the type of anaesthesia may be associated with the postprocedural neurological function in patients with anterior circulation acute ischaemic stroke undergoing endovascular treatment. Patients with acute posterior circulation ischaemic stroke may experience different physiological changes and result in severe neurological outcome. However, the effect of the type of anaesthesia on postprocedure neurological function remained unclear in this population. METHODS AND ANALYSIS This is an exploratory randomised controlled trial that will be carried out at Beijing Tiantan Hospital, Capital Medical University. Patients with acute posterior circulation ischaemic stroke and deemed suitable for emergency endovascular recanalisation will be recruited in this trial. Eighty-four patients will be randomised to receive either general anaesthesia or conscious sedation with 1:1 allocation ratio. The primary endpoint is the 90-day modified Rankin Scale. ETHICS AND DISSEMINATION The study has been reviewed by and approved by Ethics Committee of Beijing Tiantan Hospital of Capital Medical University (KY2017-074-02). If the results are positive, the study will indicate whether the type of anaesthesia affects neurological outcome after endovascular treatment of posterior stroke. The findings of the study will be published in peer-reviewed journals and presented at national or international conferences. TRIAL REGISTRATION NUMBER NCT03317535.
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Affiliation(s)
- Fa Liang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan Zhao
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiang Yan
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxuan Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiuheng Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Zhou
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Minyu Jian
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Bhogal P, Chan N, Makalanda H, Wong K, Noblet J. Transradial Woven EndoBridge device to treat a ruptured basilar tip aneurysm under conscious sedation. Interv Neuroradiol 2020; 26:779-784. [PMID: 32443960 DOI: 10.1177/1591019920927243] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We present a patient with a ruptured basilar tip aneurysm treated under conscious sedation via a right radial approach using the Woven EndoBridge device. We discuss the technical aspects of the case as the well as the available literature on the treatment of ruptured aneurysms treated without general anaesthesia. We discuss the potential benefits of the Woven EndoBridge device in such situations.
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Affiliation(s)
- P Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - N Chan
- Department of Radiology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Hld Makalanda
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - K Wong
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - J Noblet
- Department of Anaesthesia, The Royal London Hospital, London, UK
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Effect of Direct Neurologic Evaluation on Outcomes During Treatment of Unruptured Intracranial Aneurysms Under Local Anesthesia. World Neurosurg 2019; 131:e593-e598. [PMID: 31404688 DOI: 10.1016/j.wneu.2019.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The greatest advantage of local anesthesia (LA) in endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is that direct neurologic evaluation can be performed during the procedure, unlike with general anesthesia. However, the usefulness of such direct evaluation has not been established. In this study, we attempted to assess the effects of direct neurologic evaluation by identifying the causes, management, and outcomes of clinical symptoms during the procedure and procedure-related events during EVT under LA. METHODS We retrospectively evaluated the medical and radiologic data of 1000 patients (1015 UIAs) who had undergone coil embolization under LA from 2008 to 2016. RESULTS Clinical symptoms were identified in 62 patients (6.2%) during the procedure. The symptoms improved during the procedure in 27 of these patients (44%) and after the procedure in another 28 (45%). One month after the procedure, 55 patients (89%) had good outcomes and 7 (11%) had poor outcomes. Procedure-related events occurred in 67 patients (6.7%); of these 67 events, 39 were symptomatic and 28 were asymptomatic. Thirty-five of the 39 symptomatic events (90%) [13 of 13 (100%) ruptures, 6 of 10 (60%) thrombus formations, and 16 of 16 (100%) thromboembolisms] were detected on the basis of clinical symptoms before angiographic changes were identified, and they were managed promptly. All 28 patients with asymptomatic events were managed safely without further complications before symptoms developed. CONCLUSIONS We demonstrated that appropriate management of clinical symptoms and procedure-related events under LA led to favorable outcomes of EVT of UIAs.
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Tinoco CSL, Santos PMCD. Anesthetic management of endovascular treatment for acute ischemic stroke: Influences on outcome and complications. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 30195628 PMCID: PMC9391700 DOI: 10.1016/j.bjane.2018.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background and objectives The emerging use of endovascular therapies for acute ischemic stroke, like intra-arterial thrombectomy, compels a better understanding of the anesthetic management required and its impact in global outcomes. This article reviews the available data on the anesthetic management of endovascular treatment, comparing general anesthesia with conscious sedation, the most used modalities, in terms of anesthetic induction and procedure duration, patient mobility, occlusion location, hemodynamic parameters, outcome and safety; it also focuses on the state-of-the-art on physiologic and pharmacologic neuroprotection. Contents Most of the evidence on this topic is retrospective and contradictory, with only three small randomized studies to date. Conscious sedation was frequently associated with better outcomes, but the prospective evidence declared that it has no advantage over general anesthesia concerning that issue. Conscious sedation is at least as safe as general anesthesia for the endovascular treatment of acute ischemic stroke, with equivalent mortality and fewer complications like pneumonia, hypotension or extubation difficulties. It has, however, a higher frequency of patient agitation and movement, which is the main cause for conversion to general anesthesia. Conclusions General anesthesia and conscious sedation are both safe alternatives for anesthetic management of patients submitted to endovascular thrombectomy. No anesthetic management is universally recommended and hopefully the ongoing randomized clinical trials will shed some light on the best approach; meanwhile, the choice of anesthesia should be based on the patient's individual characteristics. Regarding neuroprotection, hemodynamic stability is currently the most important strategy, as no pharmacological method has been proven effective in humans.
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Tinoco CSL, Santos PMCD. [Anesthetic management of endovascular treatment for acute ischemic stroke: Influences on outcome and complications]. Rev Bras Anestesiol 2018; 68:613-623. [PMID: 30195628 DOI: 10.1016/j.bjan.2018.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 04/11/2018] [Accepted: 06/15/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The emerging use of endovascular therapies for acute ischemic stroke, like intra-arterial thrombectomy, compels a better understanding of the anesthetic management required and its impact in global outcomes. This article reviews the available data on the anesthetic management of endovascular treatment, comparing general anesthesia with conscious sedation, the most used modalities, in terms of anesthetic induction and procedure duration, patient mobility, occlusion location, hemodynamic parameters, outcome and safety; it also focuses on the state-of-the-art on physiologic and pharmacologic neuroprotection. CONTENTS Most of the evidence on this topic is retrospective and contradictory, with only three small randomized studies to date. Conscious sedation was frequently associated with better outcomes, but the prospective evidence declared that it has no advantage over general anesthesia concerning that issue. Conscious sedation is at least as safe as general anesthesia for the endovascular treatment of acute ischemic stroke, with equivalent mortality and fewer complications like pneumonia, hypotension or extubation difficulties. It has, however, a higher frequency of patient agitation and movement, which is the main cause for conversion to general anesthesia. CONCLUSIONS General anesthesia and conscious sedation are both safe alternatives for anesthetic management of patients submitted to endovascular thrombectomy. No anesthetic management is universally recommended and hopefully the ongoing randomized clinical trials will shed some light on the best approach; meanwhile, the choice of anesthesia should be based on the patient's individual characteristics. Regarding neuroprotection, hemodynamic stability is currently the most important strategy, as no pharmacological method has been proven effective in humans.
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Eker OF, Saver JL, Goyal M, Jahan R, Levy EI, Nogueira RG, Yavagal DR, Bonafé A. Impact of Anesthetic Management on Safety and Outcomes Following Mechanical Thrombectomy for Ischemic Stroke in SWIFT PRIME Cohort. Front Neurol 2018; 9:702. [PMID: 30210431 PMCID: PMC6123376 DOI: 10.3389/fneur.2018.00702] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/03/2018] [Indexed: 01/22/2023] Open
Abstract
Background and purpose: The optimal anesthetic management of acute ischemic stroke patients during mechanical thrombectomy (MT) remains controversial. In this post-hoc analysis, we investigated the impact of anesthesia type on clinical outcomes in patients included in SWIFT PRIME trial. Methods: Ninety-seven patients treated with MT were included. Patients treated in centers with general anesthesia (GA) policy (n = 32) were compared with those treated in centers with conscious sedation (CS) policy (n = 65). Primary outcomes studied included times to treatment initiation (TTI), rates of successful recanalization (TICI 2b/3), and functional independence (mRS 0–2 at 90 days). Secondary outcomes were adverse events, lowest systolic and diastolic blood pressures (LSBP and LDBP) during MT. Univariate analysis and multivariate regression logistic modeling were conducted. Results: The GA-policy and CS-policy groups presented comparable TTI (94 ± 36 min vs. 102 ± 48 min; p = 0.44), rates of TICI 2b/3 recanalization (22/32 [68.8%] vs. 51/65 [78.5%]; p = 0.32). CS-policy was associated to higher rate of functional independence than GA-policy, but the difference was not significant (43/65 [66.2%] vs. 16/32 [50.0%]; p = 0.18). GA-policy patients had a higher rate of postoperative pneumonia (11/32 [34.4%] vs. 8/65 [12.3%]; p = 0.02) and lower LSBP (110 [30,160] mmHg vs. 119 [77,170] mmHg; p = 0.03) and LDBP (55 (15,75) mmHg vs. 67 [40,121]; p < 0.001). When corrected for differences in baseline characteristics, GA-policy was associated with lower rate of functional independence (OR 0.32; p = 0.05). A 10-point increase in perprocedural LDBP was associated with an increased likelihood of favorable outcome (OR 1.51; p = 0.01). Conclusions: GA-policy for MT presented comparable TTI and rates of successful revascularization to CS-policy. However, GA-policy was associated with lower rates of functional independence and with higher incidence of perprocedural hypotension and postoperative pneumonia. Clinical Trial Registration: URL—http://www.clinicaltrials.gov. Unique identifier: NCT01657461
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Affiliation(s)
- Omer F Eker
- Department of Neuroradiology, P. Wertheimer Hospital, Hospices Civils de Lyon, Lyon, France
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Mayank Goyal
- Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Reza Jahan
- Division of Interventional Neuroradiology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Elad I Levy
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY, United States
| | - Raul G Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Dileep R Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, FL, United States
| | - Alain Bonafé
- Department of Neuroradiology, Hôpital Gui-de-Chauliac, CHU de Montpellier, Montpellier, France
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Alakbarzade V, Pereira AC. Cerebral catheter angiography and its complications. Pract Neurol 2018; 18:393-398. [PMID: 30021800 DOI: 10.1136/practneurol-2018-001986] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/15/2022]
Abstract
Catheter-based angiography is an important but invasive procedure in vascular neurology. It is used mainly for diagnosis and for planning treatment in patients with a suspected underlying vascular abnormality. It is often performed as a semiurgent, planned investigation or linked to an interventional procedure. Cerebral angiography provides high-resolution, three-dimensional, pathoanatomical data about the cerebral vasculature and also allows real-time analysis of blood flow. Contrast injections can be repeated to identify subtleties. A physical intervention may also follow angiography. For these reasons, angiography remains the gold standard for delineating vascular lesions of the brain (and spine). Permanent neurological complications are rare, approximately 1%, but become increasingly common in patients aged over 55 years. The main complications are embolic stroke, groin haematoma and contrast-induced nephropathy. In the new era of thrombectomy, it may transpire that other specialists including neurologists may learn to perform the procedure and to manage its complications.
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Affiliation(s)
- Vafa Alakbarzade
- Department of Neurology, Atkinson Morley Wing, St George's University Hospitals NHS Foundation Trust, Tooting, UK.,Department of Neurology, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Anthony C Pereira
- Department of Neurology, Atkinson Morley Wing, St George's University Hospitals NHS Foundation Trust, Tooting, UK
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Goyal N, Malhotra K, Ishfaq MF, Tsivgoulis G, Nickele C, Hoit D, Arthur AS, Alexandrov AV, Elijovich L. Current evidence for anesthesia management during endovascular stroke therapy: updated systematic review and meta-analysis. J Neurointerv Surg 2018; 11:107-113. [DOI: 10.1136/neurintsurg-2018-013916] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/01/2018] [Accepted: 05/10/2018] [Indexed: 01/30/2023]
Abstract
IntroductionDebate continues about the optimal anesthetic management for patients undergoing endovascular treatment (ET) of acute ischemic stroke due to emergent large vessel occlusion.ObjectiveTo compare, using current evidence, the clinical outcomes and procedural characteristics among patients undergoing general anesthesia (GA) and local or monitored anesthesia (non-GA).MethodsWe performed a systematic review and meta-analysis of all available studies that involved the use of stent retrievers for ET (stentriever group). Additionally, we included studies that were published in 2015 and later, and compared the clinical outcomes among the studies using stentrievers or no stentrievers (pre-stentriever group). Outcome variables included functional independence (FI; modified Rankin Scale scores of 0–2), symptomatic hemorrhage, mortality, procedure duration, and vascular and respiratory complications. We calculated pooled odds ratios and 95% CIs using random-effects models.ResultsSixteen studies (three randomized controlled clinical trials (RCTs) and 13 non-randomized studies) were identified comprising 5836 patients. Although non-GA was associated with higher odds of 3-month FI (OR=1.57; 95% CI 1.17 to 2.10; P=0.003) and lower odds of 3-month mortality (OR=0.62; 95% CI 0.47 to 0.82; P=0.0006, substantial heterogeneity was noted across included trials. Sensitivity analyses of RCTs showed that non-GA was inversely associated with FI (OR=0.55; 95% CI 0.34 to 0.89; P=0.01; I2=15%), while no association was noted with mortality (OR=1.36; 95% CI 0.79 to 2.34; P=0.27; I2=0%).ConclusionOur updated meta-analysis demonstrates favorable results with non-GA, probably owing to inclusion of non-randomized studies. Recent single-center RCTs indicate that GA is associated with higher odds of FI at 3 months, while other outcomes are similar between the two groups.
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Conscious Sedation versus General Anesthesia for Patients with Acute Ischemic Stroke Undergoing Endovascular Therapy: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2318489. [PMID: 29789778 PMCID: PMC5896359 DOI: 10.1155/2018/2318489] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/16/2018] [Indexed: 11/29/2022]
Abstract
The aim of this study is to compare the effect of conscious sedation (CS) with general anesthesia (GA) on clinical outcomes in patients with acute ischemic stroke (AIS) undergoing endovascular therapy (EVT). MEDLINE, EMBASE, and Cochrane Central Registers of Controlled Trials (from inception to July 2017) were searched for reports on CS and GA of AIS undergoing EVT. Two reviewers assessed the eligibility of the identified studies and extracted data. Data were analyzed using the fixed-effects model, and the sources of heterogeneity were explored by sensitive analysis. Trial sequential analysis was conducted to monitor boundaries for the limitation of global type I error, and GRADE system was demonstrated to evaluate the quality of evidence. A total of thirteen studies were finally identified. Pooled analysis of the incidence of mRS score ≦ 2 after hospital discharge and one or three months in the CS group was higher than that in the GA group. The all-causing mortality of AIS patients in the CS group was lower than that in the GA group. There were no differences in the proportion of IA rtPA and thrombolysis between the two groups. Compared with AIS patients receiving GA, the all-causing mortality in the AIS patients receiving CS was decreased, while incidence of mRS score ≦ 2 at hospital discharge and one or three months was increased.
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Rasmussen M, Simonsen CZ, Sørensen LH, Dyrskog S, Rusy DA, Sharma D, Juul N. Anaesthesia practices for endovascular therapy of acute ischaemic stroke: a Nordic survey. Acta Anaesthesiol Scand 2017; 61:885-894. [PMID: 28670686 DOI: 10.1111/aas.12934] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 06/07/2017] [Accepted: 06/08/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND The optimal method of anaesthesia for endovascular therapy (EVT) in acute ischaemic stroke (AIS) has not been identified. Nordic departments of anaesthesiology may handle EVT cases for AIS differently. The aim of this survey was to describe the current practice patterns of Nordic anaesthesia departments in anaesthetic management of EVT in AIS. METHODS A survey consisting of 13 questions was sent to one qualified individual at all Nordic departments of anaesthesiology who manage anaesthesia for EVT interventions. The individual completed the questionnaire on behalf of their department. RESULTS Response rate was 100%. The majority of departments (84%) managed all EVT cases at their respective centres. Most departments have institutional guidelines on anaesthetic management (84%) including blood pressure management (63%) and were able to provide a 24-h immediate response to an EVT request (63%). Conscious sedation was favoured by 68% of the departments using a variety of sedation protocols. Propofol and remifentanil was preferred for GA (58%). Emergent conversion to GA due to uncontrolled patient movements or loss of airway was experienced by 82% and 35% of the departments, respectively. Majority of the departments (89%) responded that non-specialist anaesthetists occasionally handle EVT cases. CONCLUSIONS This survey indicates that the majority of Nordic anaesthesia departments who manage anaesthesia for EVT are able to provide immediate 24-h response to an EVT request. Most of these departments have institutional guidelines for EVT anaesthesia and haemodynamic management. Conscious sedation appears to be the preferred method of anaesthetic care.
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Affiliation(s)
- M. Rasmussen
- Department of Anaesthesiology and Intensive Care; Section of Neuroanaesthesia; Aarhus University Hospital; Aarhus Denmark
- The Danish Stroke Centre; Aarhus University Hospital; Aarhus Denmark
| | - C. Z. Simonsen
- The Danish Stroke Centre; Aarhus University Hospital; Aarhus Denmark
- Department of Neurology; Aarhus University Hospital; Aarhus Denmark
| | - L. H. Sørensen
- The Danish Stroke Centre; Aarhus University Hospital; Aarhus Denmark
- Department of Neuroradiology; Aarhus University Hospital; Aarhus Denmark
| | - S. Dyrskog
- Department of Anaesthesiology and Intensive Care; Section of Neuroanaesthesia; Aarhus University Hospital; Aarhus Denmark
| | - D. A. Rusy
- Department of Anesthesiology; University of Wisconsin; Madison WI USA
| | - D. Sharma
- Department of Anesthesiology and Pain Medicine; University of Washington; Seattle WA USA
| | - N. Juul
- Department of Anaesthesiology and Intensive Care; Section of Neuroanaesthesia; Aarhus University Hospital; Aarhus Denmark
- The Danish Stroke Centre; Aarhus University Hospital; Aarhus Denmark
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Peng Y, Li Y, Jian M, Liu X, Sun J, Jia B, Dong J, Zeng M, Lin N, Zhang L, Gelb AW, Chan MTV, Han R. Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic Stroke: Protocol for a randomized controlled (CANVAS) trial. Int J Stroke 2017; 12:991-997. [PMID: 28436307 DOI: 10.1177/1747493017706243] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Observational studies indicate that the type of anesthesia, local or general, may be associated with the post-procedural neurological function in patients with acute ischemic stroke undergoing endovascular treatment. However, these results need further confirmation, and the causal relationship has not yet been established. Methods This is a randomized controlled equivalence trial. Permuted block randomization stratified by culprit vessels will be used. Six hundred and forty patients with acute ischemic stroke undergoing endovascular recanalization will be randomized one to one to receive either general anesthesia or local anesthesia. The primary endpoint is the modified Rankin scale at 90 days after endovascular treatment. The secondary endpoints are the peri-procedural mortality and morbidity. Discussion The study aims to determine the effects of anesthetic choice on neurological outcomes in patients with acute ischemic stroke undergoing intra-arterial recanalization. If the results are positive, the study will indicate that the type of anesthesia does not affect neurological outcome after endovascular treatment. Trial registration: ClinicalTrial.gov identifier: NCT02677415
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Affiliation(s)
- Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Yan Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Minyu Jian
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Jian Sun
- Department of Anesthesiology, Beijing Fuxing Hospital, Capital Medical University, Beijing, PR China
| | - Bo Jia
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Jia Dong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Nan Lin
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Li Zhang
- Division of Hematology and Medical Oncology, Department of Medicine, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Adrian W. Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew TV Chan
- Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
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15
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Schönenberger S, Bösel J. [Peri-interventional management of acute endovascular stroke treatment]. DER NERVENARZT 2016; 86:1217-25. [PMID: 26311331 DOI: 10.1007/s00115-015-4269-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Due to the ground breaking consistent evidence that supports the effect of endovascular stroke treatment (EST), many acute care hospitals and stroke centers will have to be prepared to provide this treatment in an optimal way within the coming years. In addition to the intervention itself, patient preparation, stabilization and monitoring during the treatment as well as the aftercare represent significant challenges and have mostly not yet been sufficiently investigated. Under these aspects, the questions of optimal sedation and airway management have received the highest attention. Based on retrospective study results it already seems to be justified, respecting certain criteria, to prefer EST with the patient under conscious sedation (CS) in comparison to general anesthesia (GA) and to only switch to GA in cases of emergency until this question has been clarified by prospective studies. This and other aspects of peri-interventional management, such as logistics, monitoring, blood pressure, ventilation settings, postprocedural steps of intensive or stroke unit care and imaging follow-up are summarized in this overview. The clinical and radiological selection of patients and thus the decision for intervention or technical aspects of the intervention itself will not be part of this article.
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Affiliation(s)
- S Schönenberger
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - J Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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Abstract
OPINION STATEMENT The acute treatment of major ischemic stroke has been revolutionized by strong and consistent evidence from multiple randomized trials. Endovascular treatment by mechanical thrombectomy will be increasingly chosen as an adjunctive or alternative to intravenous thrombolysis. To apply this form of stroke treatment is associated with the challenge of optimal periinterventional treatment. The patient has to be identified, counselled, prepared, monitored, cardiovascularly stabilized, possibly sedated and ventilated, and postprocedurally treated in the optimal way. However, most aspects of periinterventional treatment have as yet not been clarified and require prospective research. Among these, the question of general anesthesia vs conscious sedation has received most attention and may be the most crucial one. Based on a great amount of retrospective data, it appears reasonable to start the intervention under conscious sedation of the non-intubated patient with standby measures for emergent intubation, until prospective randomized trials have clarified that issue. Periinterventional management will significantly affect the success of recanalization.
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Affiliation(s)
- Julian Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Schönenberger S, Möhlenbruch M, Pfaff J, Mundiyanapurath S, Kieser M, Bendszus M, Hacke W, Bösel J. Sedation vs. Intubation for Endovascular Stroke TreAtment (SIESTA) – A Randomized Monocentric Trial. Int J Stroke 2015; 10:969-78. [DOI: 10.1111/ijs.12488] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 02/25/2015] [Indexed: 11/28/2022]
Abstract
Background The optimal peri-interventional management of sedation and airway for endovascular stroke treatment (EST) appears to be a crucial factor for treatment success. According to retrospective studies, the widely favored general anesthesia with intubation seems to be associated with poor functional outcome compared to a slightly sedated non-intubated condition (conscious sedation). Method SIESTA is a monocentric, prospective, randomized parallel-group, open-label treatment trial with blinded endpoint evaluation (PROBE design). The study compares the non-intubated with the intubated state in patients receiving endovascular treatment of acute ischemic anterior circulation stroke. The primary endpoint is early neurological improvement as by National Institutes of Health Stroke Scale (NIHSS) after 24 h (difference between NIHSS on admission and NIHSS after 24 h). Secondary endpoints include: functional outcome after three-months as by modified Rankin Scale (mRS), mortality, parameters of ventilation and critical care, feasibility, and safety, i.e. complications related to endovascular stroke treatment. Conclusion The aims of this study are to prospectively clarify whether the non-intubated state of conscious sedation is feasible, safe, and superior with regard to early neurological improvement compared to the intubated state of general anesthesia in patients receiving acute endovascular stroke treatment.
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Affiliation(s)
| | - Markus Möhlenbruch
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | | | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Julian Bösel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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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 2014; 7:789-94. [DOI: 10.1136/neurintsurg-2014-011373] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 09/08/2014] [Indexed: 11/04/2022]
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Should Ischemic Stroke Patients with Aphasia or High National Institutes of Health Stroke Scale Score Undergo Preprocedural Intubation and Endovascular Treatment? J Stroke Cerebrovasc Dis 2014; 23:e299-304. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 11/27/2013] [Accepted: 12/09/2013] [Indexed: 11/21/2022] Open
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McDougall CG, Albuquerque FC, Ducruet AF. Regarding "rate and prognosis of patients under conscious sedation requiring emergent intubation during neuroendovascular procedures". AJNR Am J Neuroradiol 2013; 34:E83. [PMID: 23639555 DOI: 10.3174/ajnr.a3572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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