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

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).

General anesthesia or conscious sedation for thrombectomy in stroke patients: an updated systematic review and meta-analysis

PURPOSE

Endovascular treatment for stroke patients usually requires anesthesia care, with no current consensus on the best anesthetic management strategy. Several randomized controlled trials and meta-analyses have attempted to address this. In 2022, additional evidence from three new trials was published: the GASS trial, the CANVAS II trial, and preliminary results from the AMETIS trial, prompting the execution of this updated systematic review and meta-analysis. The primary objective of this study was to evaluate the effects of general anesthesia and conscious sedation on functional outcomes measured with the modified Rankin scale (mRS) at three months.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials investigating conscious sedation and general anesthesia in endovascular treatment. The following databases were examined: PubMed, Scopus, Embase, and the Cochrane Database of Randomized Controlled Trials and Systematic Reviews. The Risk of Bias 2 tool was used to assess bias. In addition, trial sequence analysis was performed on the primary outcome to estimate if the cumulative effect is significant enough to be unaffected by further studies.

RESULTS

Nine randomized controlled trials were identified, including 1,342 patients undergoing endovascular treatment for stroke. No significant differences were detected between general anesthesia and conscious sedation with regards to mRS, functional independence (mRS, 0-2), procedure duration, onset to reperfusion, mortality, hospital length of stay, and intensive care unit length of stay. Patients treated under general anesthesia may have more frequent successful reperfusion, though the time from groin to reperfusion was slightly longer. Trial sequential analysis showed that additional trials are unlikely to show marked differences in mean mRS at three months.

CONCLUSIONS

In this updated systematic review and meta-analysis, the choice of anesthetic strategy for endovascular treatment of stroke patients did not significantly impact functional outcome as measured with the mRS at three months. Patients managed with general anesthesia may have more frequent successful reperfusion.

TRIAL REGISTRATION

PROSPERO (CRD42022319368); registered 19 April 2022.

Anaesthetic and peri-operative management for thrombectomy procedures in stroke patients

PURPOSE

To provide recommendations for the anaesthetic and peri-operative management for thrombectomy procedure in stroke patients DESIGN: A consensus committee of 15 experts issued from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation, SFAR), the Association of French-language Neuro-Anaesthetists (Association des Neuro-Anesthésistes Réanimateurs de Langue Francaise, ANARLF), the French Neuro-Vascular Society (Société Francaise de Neuro-Vasculaire, SFNV), the French Neuro-Radiology Society (Société Francaise de Neuro-Radiologie, SFNR) and the French Study Group on Haemostasis and Thrombosis (Groupe Français d'Études sur l'Hémostase et la Thrombose, GFHT) was convened, under the supervision of two expert coordinators from the SFAR and the ANARLF. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were required to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence.

METHODS

Four fields were defined prior to the literature search: (1) Peri-procedural management, (2) Prevention and management of secondary brain injuries, (3) Management of antiplatelet and anticoagulant treatments, (4) Post-procedural management and orientation of the patient. Questions were formulated using the PICO format (Population, Intervention, Comparison, and Outcomes) and updated as needed. Analysis of the literature was then conducted and the recommendations were formulated according to the GRADE methodology.

RESULTS

The SFAR/ANARLF/SFNV/SFNR/GFHT guideline panel drew up 18 recommendations regarding anaesthetic management of mechanical thrombectomy procedures. Due to a lack of data in the literature allowing to conclude with high certainty on relevant clinical outcomes, the experts decided to formulate these guidelines as "Professional Practice Recommendations" (PPR) rather than "Formalized Expert Recommendations". After two rounds of rating and several amendments, a strong agreement was reached on 100% of the recommendations. No recommendation could be formulated for two questions.

CONCLUSIONS

Strong agreement among experts was reached to provide a sizable number of recommendations aimed at optimising anaesthetic management for thrombectomy in patients suffering from stroke.

Anesthetic Management of Acute Ischemic Stroke in the Interventional Neuro-Radiology Suite: State of the Art

PURPOSE OF REVIEW

This review discusses the general anesthetic approach of endovascular stroke therapy and highlights recent advances and considerations for optimal intraoperative management of acute ischemic stroke.

RECENT FINDINGS

Recent randomized controlled trials have shown no differences in clinical outcomes between monitored anesthesia care with sedation compared with general anesthesia for endovascular stroke therapy. The COVID-19 pandemic has complicated decision-making in the neurointerventional setting. Advances in imaging techniques have extended the window of treatment for endovascular therapy.

SUMMARY

Optimal time to intervention, hemodynamic stability, novel imaging techniques, and careful consideration of anesthetic plan can impact patient outcomes in reperfusion stroke therapy.

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.

Anesthesia Considerations in Neurological Emergencies

Airway obstruction and respiratory failure are common complications of neurological emergencies. Anesthesia is often employed for airway management, surgical and endovascular interventions or in the intensive care units in patients with altered mental status or those requiring burst suppression. This article provides a summary of the unique airway management and anesthesia considerations and controversies for neurologic emergencies in general, as well as for specific commonly encountered conditions: elevated intracranial pressure, neuromuscular respiratory failure, acute ischemic stroke, and acute cervical spinal cord injury.