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Is general anaesthesia preferable to conscious sedation in the treatment of acute ischaemic stroke with intra-arterial mechanical thrombectomy? A review of the literature

  • Interventional Neuroradiology
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Abstract

Introduction

Intra-arterial mechanical thrombectomy (IAMT) is an endovascular technique that allows for the acute retrieval of intravascular thrombi and is increasingly being used for the treatment of acute ischaemic stroke (AIS). There are currently two anaesthetic options during IAMT: general anaesthesia (GA) and conscious sedation (CS). The decision to use GA versus CS is the source of controversy, as it requires careful balance between patient pain, movement and airway protection whilst minimising time delay and haemodynamic fluctuations. This review examines and summarises the evidence for the use of GA versus CS in the treatment of AIS by IAMT.

Methods

Studies were identified using systematic bibliographic searches. The five applicable studies were analysed with reference to overall outcomes and the key parameters that govern the decision to use GA or CS. The key parameters included the impact of GA and CS on pain, complication rates, time delays, airway protection and haemodynamic stability.

Results

Several retrospective analyses have shown that the use of GA is associated with adverse outcomes.

Conclusion

Intra-arterial mechanical thrombectomy under general anaesthesia is associated with poor outcomes in observational studies. It is reasonable to offer conscious sedation as the preferred option where adverse patient factors such as agitation are lacking.

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References

  1. NINDS rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1587

    Article  Google Scholar 

  2. Hacke W, Kaste M, Fieschi C et al (1995) Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke: The European Cooperative Acute Stroke Study (ECASS). J Am Med Assoc 274:1017–1025

    Article  CAS  Google Scholar 

  3. Hacke W, Kaste M, Fieschi C et al (1998) Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II): Second European-Australasian Acute Stroke Study Investigators. Lancet 352:1245–1511

    Article  PubMed  CAS  Google Scholar 

  4. Hacke W, Kaste M, Bluhmki E et al (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359:1317–1329

    Article  PubMed  CAS  Google Scholar 

  5. Mazighi M, Serfaty JM, Labreuche J et al (2009) Comparison of intravenous alteplase with a combined intravenous-endovascular approach in patients with stroke and confirmed arterial occlusion (RECANALISE study): a prospective cohort study. Lancet Neurol 8:802–809

    Article  PubMed  CAS  Google Scholar 

  6. Molina CA, Alexandrov AV, Demchuk AM, Saqqur M, Uchino K, Alvarez-Sabin J (2004) Improving the predictive accuracy of recanalization on stroke outcome in patients treated with tissue plasminogen activator. Stroke 35:151–156

    Article  PubMed  CAS  Google Scholar 

  7. Saqqur M, Uchino K, Demchuk AM et al (2007) Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke 38:948–954

    Article  PubMed  Google Scholar 

  8. Del Zoppo GJ, Poeck K, Pessin MS et al (1992) Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol 32:78–86

    Article  PubMed  Google Scholar 

  9. IMS Study Investigators (2004) Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study. Stroke 35:904–911

    Article  Google Scholar 

  10. Lewandowski CA, Frankel M, Tomsick TA et al (1999) Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial. Stroke 30:2598–2605

    Article  PubMed  CAS  Google Scholar 

  11. Del Zoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Rowley HA, Gent M (1998) PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke—PROACT Investigators. Prolyse in Acute Cerebral Thromboembolism. Stroke 29:4–11

    Article  PubMed  Google Scholar 

  12. Furlan A, Higashida R, Wechsler L et al (1999) Intra-arterial prourokinase for acute ischemic stroke: The PROACT II study—a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. J Am Med Assoc 282:2003–2011

    Article  CAS  Google Scholar 

  13. Gobin YP, Starkman S, Duckwiler GP et al (2004) Merci 1: a phase 1 study of mechanical embolus removal in cerebral ischemia. Stroke 35:2848–2854

    Article  PubMed  Google Scholar 

  14. Smith W, Sung G, Saver J et al (2008) Mechanical thrombectomy for acute ischemic stroke: final results of the Multi Merci trial. Stroke 39:1205–1212

    Article  PubMed  Google Scholar 

  15. Miteff F, Faulder KC, Goh AC, Steinfort BS, Sue C, Harrington TJ (2011) Mechanical thrombectomy with a self-expanding retrievable intracranial stent (Solitaire AB): experience in 26 patients with acute cerebral artery occlusion. Am J Neuroradiol 32:1078–1081

    Article  PubMed  CAS  Google Scholar 

  16. Varma MK, Price K, Jayakrishnan V, Manickam B, Kessell G (2007) Anaesthetic considerations for interventional neuroradiology. Br J Anaesth 99(1):75–85

    Article  PubMed  CAS  Google Scholar 

  17. Adams H, Zoppo GD, Alberts M et al (2007) Guidelines for the early management of adults with ischemic stroke. Stroke 38:1655–1711

    Article  PubMed  Google Scholar 

  18. McDonagh Dm Olson D, Kalia J, Gupta R, Abou-Chebl A, Zaidat OO (2010) Anaesthesia and sedation practices among neurointerventionalists during acute ischaemic stroke endovascular therapy. Front Neurol 1:118

    Google Scholar 

  19. Abou-Chebl A, Lin R, Hussain MS et al (2010) Conscious sedation versus general anesthesia during endovascular therapy for acute anterior circulation stroke: preliminary results from a retrospective multicenter study. Stroke 41:1175–1179

    Article  PubMed  CAS  Google Scholar 

  20. Brekenheld C, Mattle H, Schroth G (2010) General is better than local anesthesia during endovascular procedures. Stroke 41:2716–2717

    Article  Google Scholar 

  21. Jumaa M, Zhang F, Ruiz-Ares G, Gelzinis T et al (2010) Comparison of safety and clinical and radiographic outcomes in endovascular acute stroke therapy for proximal middle cerebral artery occlusion with intubation and general anesthesia versus the non-intubated state. Stroke 41:1180–1184

    Article  PubMed  Google Scholar 

  22. Davis MJ, Menon BK, Baghirzada LB, Campos-Herrera CR, Goyal M, Hill M, Archer D (2012) Anesthetic management and outcome in patients during endovascular therapy for acute stroke. Anesthesiology 116:396–405

    Article  PubMed  CAS  Google Scholar 

  23. Nichols C, Carrozzella J, Yeatts S, Tomsick T, Broderick J, Khatri P (2010) Is peri-procedural sedation during acute stroke therapy associated with poorer functional outcomes? J Neurointerv Surg 2(1):67–70. doi:10.1136/jnis.2009.001768

    Article  PubMed  CAS  Google Scholar 

  24. TIMI Study Group (1985) The thrombolysis in myocardial infarction (TIMI) trial: phase I findings. N Engl J Med 312:932–936

    Google Scholar 

  25. Abou-Chebl A, Krieger DW, Bajzer CT, Yadav JS (2006) Intracranial angioplasty and stenting in the awake patient. J Neuroimaging 16:216–223

    Article  PubMed  Google Scholar 

  26. American society of anesthesiologists (2009) Guidelines on continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. http://www.asahq.org/For-Members/Standards-Guidelines-and-Statements.aspx. Accessed 28 Mar 2012

  27. Smith WS, Sung G, Starkmann S et al (2005) Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 36:1432–1438

    Article  PubMed  Google Scholar 

  28. Khatri P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA (2009) Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology 73(13):1066–1072

    Article  PubMed  CAS  Google Scholar 

  29. Young WL (2007) Anesthesia for endovascular neurosurgery and interventional neuroradiology. Anesthesiol Clin 25:391–412

    Article  PubMed  CAS  Google Scholar 

  30. Klinger RY, White WD, Hale B, Habib AS, Bennett-Guerrero E (2012) Hemodynamic impact of dexmedetomidine administration in 15,656 non-cardiac surgical cases. J Clin Anesth 24(3):212–220

    Article  PubMed  CAS  Google Scholar 

  31. Anonymous (1999) Practice guidelines for preoperative fasting and the use of pharmacological agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: a report by the American Society of Anesthesiologist Task Force on Preoperative Fasting. Anesthesiology 90(3):896–905

    Article  Google Scholar 

  32. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R (2005) Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 36:2756–2763

    Article  PubMed  Google Scholar 

  33. Rosenberg M, Weaver J (1991) General anesthesia. Anesth Prog 38:172–186

    PubMed  CAS  Google Scholar 

  34. Ginsberg MD, Pulsinelli WA (1994) The ischemic penumbra, injury thresholds, and the therapeutic window for acute stroke. Ann Neurol 36:557–565

    Article  Google Scholar 

  35. Stead LG, Gilmore RM, Vedula KC, Weaver AL, Decker WW, Brown RD Jr (2006) Impact of acute blood pressure variability on ischaemic stroke outcome. Neurology 66(12):1878–1881

    Article  PubMed  CAS  Google Scholar 

  36. Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, Bodian CA (2005) Predictors of hypotension after induction of general anaesthesia. Anesth Analg 101(3):622–628

    Article  PubMed  Google Scholar 

  37. Alexandrov AV, Sharma VK, Lao AY, Tsivgoulis G, Malkoff MD, Alexandrov AW (2007) Reversed Robin Hood syndrome in acute ischemic stroke patients. Stroke 38:3045–3048

    Article  PubMed  Google Scholar 

  38. Ahmed A (2007) Anaesthesia for interventional neuroradiology. J Ayub Med Coll Abbottabad 19(3):80–84

    PubMed  Google Scholar 

  39. Manninen PH, Chan AS, Papworth D (1997) Conscious sedation for interventional neuroradiology: a comparison of midazolam and propofol infusion. Can J Anaesth 44(1):26–30

    Article  PubMed  CAS  Google Scholar 

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Conflict of interest

We declare that we have no conflict of interest.

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Authors and Affiliations

  1. Royal Melbourne Hospital, Grattan St, Parkville, Melbourne, Victoria, 3050, Australia

    N. John

  2. Department of Radiology, Royal Melbourne Hospital, Grattan St, Parkville, Melbourne, Victoria, 3050, Australia

    P. Mitchell & R. Dowling

  3. Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Melbourne, Victoria, 3050, Australia

    B. Yan

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  2. P. Mitchell
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  4. B. Yan
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Correspondence to B. Yan.

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John, N., Mitchell, P., Dowling, R. et al. Is general anaesthesia preferable to conscious sedation in the treatment of acute ischaemic stroke with intra-arterial mechanical thrombectomy? A review of the literature. Neuroradiology 55, 93–100 (2013). https://doi.org/10.1007/s00234-012-1084-y

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  • DOI: https://doi.org/10.1007/s00234-012-1084-y

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