Emergency Conversion to General Anesthesia Is a Tolerable Risk in Patients Undergoing Mechanical Thrombectomy

Conscious sedation by sedation-trained interventionalists versus anesthesia providers in patients with acute ischemic stroke undergoing endovascular thrombectomy: A propensity score-matched analysis

BACKGROUND

The appropriate choice of perioperative sedation during endovascular thrombectomy for ischemic stroke is unknown. Few studies have evaluated the role of nursing-administered conscious sedation supervised by a trained interventionalist.

OBJECTIVE

To compare the safety and efficacy of endovascular thrombectomy for ischemic stroke performed with nursing-administered conscious sedation supervised by a trained interventionalist with monitored anesthesia care supervised by an anesthesiologist.

METHODS

A retrospective review of a prospectively collected stroke registry was performed. The primary outcome was functional independence at 90 days, defined as a modified Rankin score of 0-2. Propensity score matching was performed to control for known confounders including patient comorbidities, access type, and direct-to-suite transfers.

RESULTS

A total of 355 patients underwent endovascular thrombectomy for large vessel occlusion between 2018 and 2022. Thirty five patients were excluded as they arrived at the endovascular suite intubated. Three hundred and twenty patients were included in our study, 155 who underwent endovascular thrombectomy with nursing-administered conscious sedation and 165 who underwent endovascular thrombectomy with monitored anesthesia care. After propensity score matching, there were 111 patients in each group. There was no difference in modified Rankin score 0-2 at 90 days (26.1% vs 35.1%, p = 0.190). Patients undergoing monitored anesthesia care received significantly more vasoactive medications (23.4% vs 49.5%, p < 0.001) and had a lower intraoperative minimum systolic blood pressure (134 vs 123 mmHg, p < 0.046). There was no difference in procedural efficacy, safety, intubation rates, and postoperative complications.

CONCLUSION

Perioperative sedation with nursing-administered conscious sedation may be safe and effective in patients undergoing endovascular thrombectomy for ischemic stroke.

Factors influencing the need for emergent conversion to general anesthesia during mechanical thrombectomy in acute anterior circulation stroke - A retrospective observational study

BACKGROUND

Endovascular mechanical thrombectomy (EMT) for acute ischemic stroke can be conducted under conscious sedation (CS) or general anesthesia (GA). Emergency conversion from CS to GA during the procedure can occur, but its predictors and impact on clinical outcomes are not fully understood.

METHODS

A single centre retrospective analysis was conducted on 226 patients who underwent EMT for anterior circulation stroke. Two groups were identified: patients who completed the procedure under CS and those requiring emergency conversion to GA. The predictors of emergency conversion to GA and its impact on clinical outcomes were analyzed.

RESULTS

Forty-five patients (19.9%) required conversion to GA. Atrial fibrillation (OR 2.38; CI 1.09-5.22; p = 0.03) and prolonged duration of procedure (OR 1.02; CI 1.01-1.04; p < 0.001) were identified as the independent predictors of emergency conversion to GA.

CONCLUSION

Patients with atrial fibrillation and prolonged duration of procedure especially when utilizing combined aspiration-stent retriever or angioplasty/stenting techniques, had a higher likelihood of requiring emergency conversion to general anesthesia (GA).

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.

Effects of an Infection Control Protocol for Coronavirus Disease in Emergency Mechanical Thrombectomy

Objective

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, neurointerventionists have been increasingly concerned regarding the prevention of infection and time delay in performing emergency thrombectomy procedures in patients with acute stroke. This study aimed to analyze the effects of changes in mechanical thrombectomy protocol before and after the COVID-19 pandemic on procedure time and patient outcomes and to identify factors that significantly impact procedure time.

Methods

The last-normal-to-door, first-abnormal-to-door, door-to-imaging, door-to-puncture, and puncture-to-recanalization times of 88 patients (45 treated with conventional pre-COVID-19 protocol and 43 with COVID-19 protection protocol) were retrospectively analyzed. The recanalization time, success rate of mechanical thrombectomy, and modified Rankin score of patients at discharge were assessed. A multivariate analysis was conducted to identify variables that significantly influenced the time delay in the door-to-puncture time and total procedure time.

Results

The door-to-imaging time significantly increased under the COVID-19 protection protocol (p=0.0257) compared to that with the conventional pre-COVID-19 protocol. This increase was even more pronounced in patients who were suspected to be COVID-19-positive than in those who were negative. The door-to-puncture time showed no statistical difference between the conventional and COVID-19 protocol groups (p=0.5042). However, in the multivariate analysis, the last-normal-to-door time and door-to-imaging time were shown to affect the door-to-puncture time (p=0.0068 and 0.0097). The total procedure time was affected by the occlusion site, last-normal-to-door time, door-to-imaging time, and type of anesthesia (p=0.0001, 0.0231, 0.0103, and 0.0207, respectively).

Conclusion

The COVID-19 protection protocol significantly impacted the door-to-imaging time. Shortening the door-to-imaging time and performing the procedure under local anesthesia, if possible, may be required to reduce the door-to-puncture and door-to-recanalization times. The effect of various aspects of the protection protocol on emergency thrombectomy should be further studied.

Monitored anesthesia care during mechanical thrombectomy for stroke: need for data-driven and individualized decisions

BACKGROUND

The optimal anesthesia management for patients with stroke undergoing mechanical thrombectomy (MT) during the COVID-19 pandemic has become a matter of controversy. Some recent guidelines have favored general anesthesia (GA) in patients perceived as high risk for intraprocedural conversion from sedation to GA, including those with dominant hemispheric occlusions/aphasia or baseline National Institutes of Health Stroke Scale (NIHSS) score >15. We aim to identify the rate and predictors of conversion to GA during MT in a high-volume center where monitored anesthesia care (MAC) is the default modality.

METHODS

A retrospective review of a prospectively maintained MT database from January 2013 to July 2020 was undertaken. Analyses were conducted to identify the predictors of intraprocedural conversion to GA. In addition, we analyzed the GA conversion rates in subgroups of interest.

RESULTS

Among 1919 MT patients, 1681 (87.6%) started treatment under MAC (median age 65 years (IQR 55-76); baseline NIHSS 16 (IQR 11-21); 48.4% women). Of the 1677 eligible patients, 26 (1.6%) converted to GA including 1.4% (22/1615) with anterior and 6.5% (4/62) with posterior circulation strokes. The only predictor of GA conversion was posterior circulation stroke (OR 4.99, 95% CI 1.67 to 14.96, P=0.004). The conversion rates were numerically higher in right than in left hemispheric occlusions (1.6% vs 1.2%; OR 1.37, 95% CI 0.59 to 3.19, P=0.47) and in milder than in more severe strokes (NIHSS ≤15 vs >15: 2% vs 1.2%; OR 0.62, 95% CI 0.28 to 1.36, P=0.23).

CONCLUSIONS

Our study showed that the overall rate of conversion from MAC to GA during MT was low (1.6%) and, while higher in posterior circulation strokes, it was not predicted by either hemispheric dominance or stroke severity. Caution should be given before changing clinical practice during moments of crisis.

Impact of anesthetic strategy on outcomes for patients with acute basilar artery occlusion undergoing mechanical thrombectomy

BACKGROUND

The best anesthetic management strategy for patients with acute large vessel occlusion treated with mechanical thrombectomy (MT) remains uncertain. Most studies have focused on anterior-circulation stroke caused by large artery occlusion. Nevertheless, limited data are available on the appropriate choice of anesthetic for acute basilar artery occlusion (BAO). We aimed to investigate the effect of anesthetic method on clinical outcomes in patients with BAO undergoing MT.

METHODS

Patients undergoing MT for acute BAO in the BASILAR registry (Acute Basilar Artery Occlusion Study) were included. We divided patients into three groups according to the anesthetic technique used during MT: general anesthesia (GA), local anesthesia (LA), and conscious sedation (CS). Propensity score matching was performed to achieve baseline balance.

RESULTS

639 patients were included. GA was used in 257 patients (40.2%), LA was used in 250 patients (39.1%), and CS was used in 132 patients (20.7%). After 1:1 matching, favorable outcome, mortality, and hemorrhagic transformation rates, as well as modified Rankin Scale (mRS) score at 90 days, did not differ between the GA, LA, and CS groups.

CONCLUSIONS

The choice of anesthetic strategy, GA, LA, or CS, did not affect the clinical outcomes of patients with acute BAO treated with MT in the BASILAR registry.

Emergency intubation during thrombectomy for acute ischemic stroke in patients under primary procedural sedation

Background

Emergency intubation is an inherent risk of procedural sedation regimens for endovascular treatment (EVT) of acute ischemic stroke. We aimed to characterize the subgroup of patients, who had to be emergently intubated, to identify predictors of the need for intubation and assess their outcomes.

Methods

This is a retrospective analysis of the single-center study KEEP SIMPLEST, which evaluated a new in-house SOP for EVT under primary procedural sedation. We used descriptive statistics and regression models to examine predictors and functional outcome of emergently intubated patients.

Results

Twenty of 160 (12.5%) patients were emergently intubated. National Institutes of Health Stroke Scale (NIHSS) on admission, premorbid modified Rankin scale (mRS), Alberta Stroke Program Early CT Score, age and side of occlusion were not associated with need for emergency intubation. Emergency intubation was associated with a lower rate of successful reperfusion (OR, 0.174; 95%-CI, 0.045 to 0.663; p = 0.01). Emergently intubated patients had higher in-house mortality (30% vs 6.4%; p = 0.001) and a lower rate of mRS 0–2 at 3 months was observed in those patients (10.5% vs 37%, p = 0.024).

Conclusions

Emergency intubation during a primary procedural sedation regimen for EVT was associated with lower rate of successful reperfusion. Less favorable outcome was observed in the subgroup of emergently intubated patients. More research is required to find practical predictors of intubation need and to determine, whether emergency intubation is safe under strict primary procedural sedation regimens for EVT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-021-00125-0.

Local anesthesia as a distinct comparator versus conscious sedation and general anesthesia in endovascular stroke treatment: a systematic review and meta-analysis

BACKGROUND

The optimal anesthetic modality for endovascular treatment (EVT) in acute ischemic stroke (AIS) is undetermined. Comparisons of general anesthesia (GA) with composite non-GA cohorts of conscious sedation (CS) and local anesthesia (LA) without sedation have provided conflicting results. There has been emerging interest in assessing whether LA alone may be associated with improved outcomes. We conducted a systematic review and meta-analysis to evaluate clinical and procedural outcomes comparing LA with CS and GA.

METHODS

We reviewed the literature for studies reporting outcome variables in LA versus CS and LA versus GA comparisons. The primary outcome was 90 day good functional outcome (modified Rankin Scale (mRS) score of ≤2). Secondary outcomes included mortality, symptomatic intracerebral hemorrhage, excellent functional outcome (mRS score ≤1), successful reperfusion (Thrombolysis in Cerebral Infarction (TICI) >2b), procedural time metrics, and procedural complications. Random effects meta-analysis was performed on unadjusted and adjusted data.

RESULTS

Eight non-randomized studies of 7797 patients (2797 LA, 2218 CS, and 2782 GA) were identified. In the LA versus GA comparison, no statistically significant differences were found in unadjusted analyses for 90 day good functional outcome or mortality (OR=1.22, 95% CI 0.84 to 1.76, p=0.3 and OR=0.83, 95% CI 0.64 to 1.07, p=0.15, respectively) or in the LA versus CS comparison (OR=1.14, 95% CI 0.76 to 1.71, p=0.53 and OR=0.88, 95% CI 0.62 to 1.24, p=0.47, respectively). There was a tendency towards achieving excellent functional outcome (mRS ≤1) in the LA group versus the GA group (OR=1.44, 95% CI 1.00 to 2.08, p=0.05, I²=70%). Analysis of adjusted data demonstrated a tendency towards higher odds of death at 90 days in the GA versus the LA group (OR=1.24, 95% CI 1.00 to 1.54, p=0.05, I²=0%).

CONCLUSION

LA without sedation was not significantly superior to CS or GA in improving outcomes when performing EVT for AIS. However, the quality of the included studies impaired interpretation, and inclusion of an LA arm in future well designed multicenter, randomized controlled trials is warranted.

General Anesthesia versus Conscious Sedation in Mechanical Thrombectomy

Background and Purpose

Anesthesia regimen in patients undergoing mechanical thrombectomy (MT) is still an unresolved issue.

Methods

We compared the effect of anesthesia regimen using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) between June 2015 and December 2019. Degree of disability was rated by the modified Rankin Scale (mRS), and good outcome was defined as mRS 0–2. Successful reperfusion was assumed when the modified thrombolysis in cerebral infarction scale was 2b–3.

Results

Out of 6,635 patients, 67.1% (n=4,453) patients underwent general anesthesia (GA), 24.9% (n=1,650) conscious sedation (CS), and 3.3% (n=219) conversion from CS to GA. Rate of successful reperfusion was similar across all three groups (83.0% vs. 84.2% vs. 82.6%, P=0.149). Compared to the CA-group, the GA-group had a delay from admission to groin (71.0 minutes vs. 61.0 minutes, P<0.001), but a comparable interval from groin to flow restoration (41.0 minutes vs. 39.0 minutes). The CS-group had the lowest rate of periprocedural complications (15.0% vs. 21.0% vs. 28.3%, P<0.001). The CS-group was more likely to have a good outcome at follow-up (42.1% vs. 34.2% vs. 33.5%, P<0.001) and a lower mortality rate (23.4% vs. 34.2% vs. 26.0%, P<0.001). In multivariable analysis, GA was associated with reduced achievement of good functional outcome (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.71 to 0.94; P=0.004) and increased mortality (OR, 1.42; 95% CI, 1.23 to 1.64; P<0.001). Subgroup analysis for anterior circulation strokes (n=5,808) showed comparable results.

Conclusions

We provide further evidence that CS during MT has advantages over GA in terms of complications, time intervals, and functional outcome.

Neuroanesthesiology Update

This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.

Patients Requiring Conversion to General Anesthesia during Endovascular Therapy Have Worse Outcomes: A Post Hoc Analysis of Data from the SAGA Collaboration

BACKGROUND AND PURPOSE

Endovascular therapy for acute ischemic stroke is often performed with the patient under conscious sedation. Emergent conversion from conscious sedation to general anesthesia is sometimes necessary. The aim of this study was to assess the functional outcome in converted patients compared with patients who remained in conscious sedation and to identify predictors associated with the risk of conversion.

MATERIALS AND METHODS

Data from 368 patients, included in 3 trials randomizing between conscious sedation and general anesthesia before endovascular therapy (SIESTA, ANSTROKE, and GOLIATH) constituted the study cohort. Twenty-one (11%) of 185 patients randomized to conscious sedation were emergently converted to general anesthesia.

RESULTS

Absence of hyperlipidemia seemed to be the strongest predictor of conversion to general anesthesia, albeit a weak predictor (area under curve = 0.62). Sex, hypertension, diabetes, smoking status, atrial fibrillation, blood pressure, size of the infarct, and level and side of the occlusion were not significantly associated with conversion to general anesthesia. Neither age (mean age, 71.3   ± 13.8 years for conscious sedation versus 71.6  ± 12.3 years for converters, P = .58) nor severity of stroke (mean NIHSS score, 17 ± 4 versus 18 ± 4, respectively, P = .27) were significantly different between converters and those who tolerated conscious sedation. The converters had significantly worse outcome with a common odds ratio of 2.67 (P = .015) for a shift toward a higher mRS score compared with the patients remaining in the conscious sedation group.

CONCLUSIONS

Patients undergoing conversion had significantly worse outcome compared with patients remaining in conscious sedation. No factor was identified that predicted conversion from conscious sedation to general anesthesia.