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Anesthesia for Endovascular Therapy for Acute Ischemic Stroke in Adults

Editor: Paramvir Singh Updated: 1/29/2023 9:22:37 AM

Introduction

Approximately 795000 people suffer from stroke annually in the US. By this estimate, one person gets a stroke every 40 seconds, and approximately one patient dies due to stroke every 4 minutes.[1]

Acute stroke can be classified as ischemic, hemorrhagic, subarachnoid, cerebral thrombosis, and spinal stroke.[2]

About 80 to 87% of all strokes are of ischemic origin. Ischemic stroke is further divided into five subtypes:[3][4][5]

  1. Large-artery atherosclerosis
  2. Cardioembolism
  3. Small-vessel occlusion
  4. Stroke of other determined etiology
  5. Stroke of undetermined etiology

Risk factors of stroke can be divided into modifiable and non-modifiable. Modifiable factors are hypertension, diabetes, hyperlipidemia, tobacco use, alcohol and drug use, physical inactivity, atrial fibrillation. Non-modifiable factors are age, sex, race, genetics.

Anatomy and Physiology

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Anatomy and Physiology

Cerebral Circulation: Arterial System and Venous System

The arterial blood flow to the brain is through two major sources: the anterior source is provided by internal carotid arteries, and the posterior source originates in vertebral arteries. Internal carotid and vertebral arteries confluence at the circle of Willis, and from there, all the major cerebral arteries arise. Thus, arteries supplying brain tissue are the anterior cerebral artery, middle cerebral artery, anterior choroidal artery, posterior cerebral artery, anterior inferior cerebellar artery, posterior inferior cerebellar artery, basilar artery.

Cerebral venous system: superficial dural venous sinuses and deep cerebral veins.[6]

Acute Ischemic stroke (AIS) is caused by deficient blood and oxygen supply to the brain; hemorrhagic stroke is caused by bleeding or leaky blood vessels.

Pathophysiology

In ischemic stroke, acute occlusion of blood vessels is most commonly embolic, while rupture of atherosclerotic plaque is a less common cause.[7] This leads to a reduction in blood flow and cell death.

Approximately 10 to 15% of all strokes are hemorrhagic in nature (caused by ruptured blood vessels) and are associated with high mortality.

After an acute stroke, the area of ischemic brain tissue (core) is surrounded by reversibly damaged tissue called the penumbra.[8] This tissue is salvageable and is the focus of stroke treatment.[9]

Indications

Indications of endovascular therapy in acute ischemic stroke are patients who present late. They are out of the window for intravenous recombinant-type tissue plasminogen activator (IV rtPA) therapy, who have contraindications to IV rtPA therapy (e.g., recent surgery or coagulopathy), or who have failed IV rtPA therapy.[10]

Outcomes are favorable in patients who receive thrombectomy and standard medical care within 6 to 24 hours of the onset of symptoms.[11]

Equipment

For brain imaging, e.g., non-contrast computed tomography (NCCT), diffusion weight magnetic resonance imaging (DW-MRI)

Cerebral Angiography

  • Airway equipment, endotracheal tubes, laryngoscopes, glide scopes
  • Anesthesia machine
  • Oxygen
  • Anesthesia induction agents, propofol, etomidate, people with paralysis
  • Vasoactive medications such as vasopressors and anti-hypertensive drugs
  • Ultrasound machine for rapid vascular access/arterial line cannulation
  • Arterial blood gas analyzer
  • Glucometers

For Mechanical Thrombectomy

  • Stent retriever
  • Mechanical embolus removal in cerebral ischemia (MERCI) device
  • The proximal balloon guide catheter
  • A large-bore distal access catheter
  • Cervical guide catheter

Standard American Society of Anesthesiology (ASA) monitors like, pulse oximeter, electrocardiogram, noninvasive and invasive blood pressure monitoring, temperature monitoring, end-tidal carbon dioxide monitor.

Personnel

Interprofessional care team, including emergency department personnel, neuro-interventionalists, anesthesiologists, neurologists, neurosurgeons, neurocritical care specialists, nurses, technicians.

Preparation

Mechanical thrombectomy is an emergent procedure. Therefore, neuro-angiography suite/operating room (OR) should be prepared well in advance for endovascular treatment of stroke to avoid any delay in anesthesia. An anesthesia machine should be checked and be ready to go. Airway equipment, monitoring devices, venous access kits, and drugs should be ready for starting and maintaining anesthesia.

Technique or Treatment

Hemorrhagic Stroke

Treatment modalities for hemorrhagic stroke mainly revolve around hypertension control and surgical evacuation of the hematoma.[12][13] The benefits of either of these interventions in improving the outcome of hemorrhagic stroke are uncertain. Studies comparing the effect of target systolic blood pressure of 110 to 139 mmHg vs. 140 to 179 mmHg did not show a reduction in mortality and morbidity in patients suffering from hemorrhagic stroke.[14] Early surgery for hematoma evacuation has some survival benefits.[15]

Acute Ischemic Stroke (AIS)

Brain tissue is lost rapidly after stroke, and hence, time is brain concept was introduced to emphasize the need for emergent evaluation and treatment to limit its progress.[16] Quantitative neurostereology and stroke neuroimaging show that for every minute of untreated large vessel stroke, the brain loses approximately 1.9 million neurons. Therefore, one of the significant anesthetic concerns is the preservation of the penumbra region. It lasts only a few hours on humans.[17] Every attempt should be made to avoid the delay of anesthesia.

There is an ongoing debate about the effectiveness of general anesthesia (GA) over conscious sedation and vice versa, as some studies have shown that GA is associated with a lower disability while others demonstrated worse outcomes with GA.[18][19][20][21]

Anastasian enumerated the advantages and disadvantages of GA and local anesthesia.[10] Advantages of GA are immobility, pain control, and airway protection, while disadvantages are more hemodynamic changes and time delay at the start of the procedure. Advantages of local anesthesia are superior hemodynamics and neurological evaluation, while the disadvantages are patient movement, pain, and agitation, loss of airway control.

American Heart Association/ American Stroke Association (AHA/ASA) guidelines recommend that the choice of anesthetic technique should be based on patient risk factors, clinical conditions, and technical performance of the procedure. They recommend that either method, i.e., GA or procedural sedation is reasonable until more data is available. Society for neuroscience in anesthesiology and critical care (SNACC) expert consensus statement also recommends that the choice of anesthesia should be tailored according to the patient’s clinical condition.[22][23]

Blood pressure, heart rate, electrocardiogram, oxygen saturation, end-tidal carbon dioxide concentration should be continuously monitored throughout the procedure. Invasive arterial blood pressure should be employed to monitor beat-to-beat pressure.[23]

Hypertension is present in about 80% of patients presenting with acute ischemic stroke.[24]

A U-shaped relationship exists between blood pressure and neurological outcome, with hypertension and hypotension, with both associated with poor outcomes. Data shows that the best neurological outcomes are observed at a systolic blood pressure of 150 mmHg (range between 140 to 179 mmHg).[25] Diastolic blood pressure should be maintained at < 105 mmHg.[23]

AHA/ASA guidelines recommend maintaining BP ≤180/105 mmHg during and for 24 hours after mechanical thrombectomy.

For patients presenting with hypertension in the setting of AIS, the overall clinical picture should be taken into account, e.g., patients with acute coronary syndrome, acute heart failure, aortic dissection, or post thrombolysis symptomatic intracerebral hemorrhage. In these cases, the initial lowering of BP should not be more than 15% of baseline.[22]

Different antihypertensive options to control BP as recommended by AHA/ASA are:

  • Labetalol 10 to 20 mg IV over 1 to 2 min, may repeat one time; or
  • Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5 to 15 min, maximum 15 mg/h;
  • Clevidipine 1 to 2 mg/h IV, titrate by doubling the dose every 2 to 5 min until desired BP reached; maximum 21 mg/h
  • Other agents (e.g., hydralazine, enalaprilat) may also be considered.

If BP is not controlled or diastolic BP >140 mm Hg, IV sodium nitroprusside can be considered.

Anesthesia should be planned in a way that avoids hypotension and acute fluctuations in blood pressure, as they are associated with loss of penumbra.[26]

Hypotension is associated with poor outcomes in the setting of acute ischemic stroke.[10] Systolic blood pressure of <140 mmHg is an independent predictor of poor neurologic outcome.

Hypotension and hypovolemia should be corrected to achieve hemodynamic stability and organ perfusion, and excessive volume expansion is not recommended as it may lead to hemodilution. If hypoglycemia is not a concern, non-glucose-containing fluids should be used.

Aspirin should be administered in patients with AIS within 24 to 48 hours after onset, but it should not be used as a substitute to the treatment by either thrombolysis or mechanical thrombectomy.

Supplemental oxygen should be used to maintain oxygen saturation >94%, or PaO2 > 60 mmHg.[27] All the measures should be taken to avoid hypoxia, hypercapnia, and hypocapnia.

Body temperature should be maintained in a range of 35 to 37 degrees centigrade. Causes of hyperthermia (temperature >38 degrees C) should be identified and treated. Antipyretic medications and cooling devices should be used to correct the temperature when needed.

Blood sugar should be closely monitored, and hypoglycemia (blood glucose <60 mg/dL) and hyperglycemia should be avoided. AHA/ASA recommends target blood sugar levels of 140 to 180 mg/dl range.[22] SNACC consensus statement recommends maintaining blood sugar levels between 70 to 140 mg/dl.[23]

Routine use of prophylactic antibiotics, antiseizure drugs, and flathead positioning has not been proven beneficial.

After the procedure, the patient should be transferred to the neuro-critical care unit for continued hemodynamic and neurological monitoring.

Complications

Potential complications are intracranial hemorrhage, vessel dissection, emboli to new vascular territories, vasospasm, stent dislocation/occlusion, extravasation.[28][29]

Clinical Significance

Avoidance of delay in anesthesia and hence treatment of acute ischemic stroke cannot be emphasized more. More delay causes more loss of penumbra and hence worse outcomes. Provision of hemodynamic stability is one of the most important anesthetic goals for patients undergoing mechanical thrombectomy for acute ischemic stroke.

Enhancing Healthcare Team Outcomes

Management of a patient with acute ischemic stroke requires a multidisciplinary effort, with multiple teams working at different levels and in coordination with each other. This requires efficient communication between teams. Code stroke should be initiated so that all teams are ready to deliver their responsibilities. For example, when the patient arrives in ED, physicians (ED physician, neurologist, anesthesiologist) should quickly assess the patient, stabilize them and send for a CT scan.

Meanwhile, nursing staff and technicians should be ready for the scan. If it is determined that the patient has an acute ischemic stroke and has no contraindications and is within the time frame of intravenous recombinant tissue plasminogen activator treatment, it should be administered. If not, then he should be taken to OR, avoiding any delay for mechanical thrombectomy.

The anesthesiologist should decide if he would require general anesthesia or conscious sedation depending on the clinical situation. Intraoperatively, care should be provided according to standard management protocols (AHA/ASA guidelines, SNACC recommendations), maintaining hemodynamic and metabolic parameters, providing adequate oxygenation and ventilation, all with an intent to salvage penumbra and limit neurological disability.

Nursing, Allied Health, and Interprofessional Team Interventions

Whenever a patient with suspected acute stroke symptoms presents, code stroke is called, and many different teams come into play. They work together and in succession to give the best care possible. With so many different persons working together, efficient communication becomes important.

Different teams may decide on doing interventions at different times during the hospital stay, such as ED physician/anesthesiologist may decide to intubate the patient if he thinks the patient’s consciousness is declining, a neurologist may decide on starting thrombolysis/thrombectomy and an interventional radiologist may help with mechanical thrombectomy. Also, the different teams may get involved to treat complications of stroke or its treatment. Good communication is valuable in all these scenarios.

Nursing, Allied Health, and Interprofessional Team Monitoring

Given the complexity of the procedure and co-morbidities associated with the patient, the importance of vigilant monitoring cannot be emphasized more. Neurologic parameters (consciousness, mental status), hemodynamic parameters (hypo/hypertension, cardiac rhythms, heart rate), metabolic parameters (blood sugar, renal function), and other clinical factors such as temperature should be continuously monitored. Effective communication should be established between the interprofessional team, and adequate interventions should be carried out in the best interest of the patients.

References


[1]

Benjamin EJ,Blaha MJ,Chiuve SE,Cushman M,Das SR,Deo R,de Ferranti SD,Floyd J,Fornage M,Gillespie C,Isasi CR,Jiménez MC,Jordan LC,Judd SE,Lackland D,Lichtman JH,Lisabeth L,Liu S,Longenecker CT,Mackey RH,Matsushita K,Mozaffarian D,Mussolino ME,Nasir K,Neumar RW,Palaniappan L,Pandey DK,Thiagarajan RR,Reeves MJ,Ritchey M,Rodriguez CJ,Roth GA,Rosamond WD,Sasson C,Towfighi A,Tsao CW,Turner MB,Virani SS,Voeks JH,Willey JZ,Wilkins JT,Wu JH,Alger HM,Wong SS,Muntner P,American Heart Association Statistics Committee and Stroke Statistics Subcommittee., Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation. 2017 Mar 7;     [PubMed PMID: 28122885]


[2]

Amarenco P,Bogousslavsky J,Caplan LR,Donnan GA,Hennerici MG, Classification of stroke subtypes. Cerebrovascular diseases (Basel, Switzerland). 2009;     [PubMed PMID: 19342825]


[3]

Dietl M,Pohle R,Weingärtner M,Polgar R,Grässel E,Schwab S,Kolominsky-Rabas P, [Stroke etiology and long-term need of care in ischemic stroke patients]. Fortschritte der Neurologie-Psychiatrie. 2009 Dec;     [PubMed PMID: 19950047]


[4]

Kuriakose D,Xiao Z, Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. International journal of molecular sciences. 2020 Oct 15;     [PubMed PMID: 33076218]

Level 3 (low-level) evidence

[5]

Adams HP Jr,Bendixen BH,Kappelle LJ,Biller J,Love BB,Gordon DL,Marsh EE 3rd, Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993 Jan;     [PubMed PMID: 7678184]

Level 1 (high-level) evidence

[6]

Chandra A,Li WA,Stone CR,Geng X,Ding Y, The cerebral circulation and cerebrovascular disease I: Anatomy. Brain circulation. 2017 Apr-Jun;     [PubMed PMID: 30276305]


[7]

Musuka TD,Wilton SB,Traboulsi M,Hill MD, Diagnosis and management of acute ischemic stroke: speed is critical. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2015 Sep 8;     [PubMed PMID: 26243819]


[8]

Liu S,Levine SR,Winn HR, Targeting ischemic penumbra: part I - from pathophysiology to therapeutic strategy. Journal of experimental stroke     [PubMed PMID: 20607107]


[9]

Ramos-Cabrer P,Campos F,Sobrino T,Castillo J, Targeting the ischemic penumbra. Stroke. 2011 Jan;     [PubMed PMID: 21164112]


[10]

Anastasian ZH, Anaesthetic management of the patient with acute ischaemic stroke. British journal of anaesthesia. 2014 Dec;     [PubMed PMID: 25498583]


[11]

Nogueira RG,Jadhav AP,Haussen DC,Bonafe A,Budzik RF,Bhuva P,Yavagal DR,Ribo M,Cognard C,Hanel RA,Sila CA,Hassan AE,Millan M,Levy EI,Mitchell P,Chen M,English JD,Shah QA,Silver FL,Pereira VM,Mehta BP,Baxter BW,Abraham MG,Cardona P,Veznedaroglu E,Hellinger FR,Feng L,Kirmani JF,Lopes DK,Jankowitz BT,Frankel MR,Costalat V,Vora NA,Yoo AJ,Malik AM,Furlan AJ,Rubiera M,Aghaebrahim A,Olivot JM,Tekle WG,Shields R,Graves T,Lewis RJ,Smith WS,Liebeskind DS,Saver JL,Jovin TG,DAWN Trial Investigators., Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. The New England journal of medicine. 2018 Jan 4;     [PubMed PMID: 29129157]


[12]

Qureshi AI,Qureshi MH, Acute hypertensive response in patients with intracerebral hemorrhage pathophysiology and treatment. Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism. 2018 Sep;     [PubMed PMID: 28812942]


[13]

Wilkinson DA,Keep RF,Hua Y,Xi G, Hematoma clearance as a therapeutic target in intracerebral hemorrhage: From macro to micro. Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism. 2018 Apr;     [PubMed PMID: 29350086]


[14]

Qureshi AI,Palesch YY,Barsan WG,Hanley DF,Hsu CY,Martin RL,Moy CS,Silbergleit R,Steiner T,Suarez JI,Toyoda K,Wang Y,Yamamoto H,Yoon BW,ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network., Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. The New England journal of medicine. 2016 Sep 15;     [PubMed PMID: 27276234]


[15]

Mendelow AD,Gregson BA,Rowan EN,Murray GD,Gholkar A,Mitchell PM,STICH II Investigators., Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet (London, England). 2013 Aug 3;     [PubMed PMID: 23726393]

Level 1 (high-level) evidence

[16]

Saver JL, Time is brain--quantified. Stroke. 2006 Jan;     [PubMed PMID: 16339467]


[17]

Saver JL, The 2012 Feinberg Lecture: treatment swift and treatment sure. Stroke. 2013 Jan;     [PubMed PMID: 23238857]


[18]

Schönenberger S,Hendén PL,Simonsen CZ,Uhlmann L,Klose C,Pfaff JAR,Yoo AJ,Sørensen LH,Ringleb PA,Wick W,Kieser M,Möhlenbruch MA,Rasmussen M,Rentzos A,Bösel J, Association of General Anesthesia vs Procedural Sedation With Functional Outcome Among Patients With Acute Ischemic Stroke Undergoing Thrombectomy: A Systematic Review and Meta-analysis. JAMA. 2019 Oct 1;     [PubMed PMID: 31573636]

Level 1 (high-level) evidence

[19]

Zhang Y,Jia L,Fang F,Ma L,Cai B,Faramand A, General Anesthesia Versus Conscious Sedation for Intracranial Mechanical Thrombectomy: A Systematic Review and Meta-analysis of Randomized Clinical Trials. Journal of the American Heart Association. 2019 Jun 18;     [PubMed PMID: 31181981]

Level 1 (high-level) evidence

[20]

Cappellari M,Pracucci G,Forlivesi S,Saia V,Nappini S,Nencini P,Inzitari D,Greco L,Sallustio F,Vallone S,Bigliardi G,Zini A,Pitrone A,Grillo F,Musolino R,Bracco S,Tinturini R,Tassi R,Bergui M,Cerrato P,Saletti A,De Vito A,Casetta I,Gasparotti R,Magoni M,Castellan L,Malfatto L,Menozzi R,Scoditti U,Causin F,Baracchini C,Puglielli E,Casalena A,Ruggiero M,Malatesta E,Comelli C,Chianale G,Lauretti DL,Mancuso M,Lafe E,Cavallini A,Cavasin N,Critelli A,Ciceri EFM,Bonetti B,Chiumarulo L,Petruzzelli M,Giorgianni A,Versino M,Ganimede MP,Tinelli A,Auteri W,Petrone A,Guidetti G,Nicolini E,Allegretti L,Tassinari T,Filauri P,Sacco S,Pavia M,Invernizzi P,Nuzzi NP,Carmela Spinelli M,Amistà P,Russo M,Ferrandi D,Corraine S,Craparo G,Mannino M,Simonetti L,Toni D,Mangiafico S, General Anesthesia Versus Conscious Sedation and Local Anesthesia During Thrombectomy for Acute Ischemic Stroke. Stroke. 2020 Jul;     [PubMed PMID: 32517584]

Level 3 (low-level) evidence

[21]

Davis MJ,Menon BK,Baghirzada LB,Campos-Herrera CR,Goyal M,Hill MD,Archer DP,Calgary Stroke Program., Anesthetic management and outcome in patients during endovascular therapy for acute stroke. Anesthesiology. 2012 Feb;     [PubMed PMID: 22222475]

Level 2 (mid-level) evidence

[22]

Powers WJ,Rabinstein AA,Ackerson T,Adeoye OM,Bambakidis NC,Becker K,Biller J,Brown M,Demaerschalk BM,Hoh B,Jauch EC,Kidwell CS,Leslie-Mazwi TM,Ovbiagele B,Scott PA,Sheth KN,Southerland AM,Summers DV,Tirschwell DL, Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;     [PubMed PMID: 31662037]


[23]

Talke PO,Sharma D,Heyer EJ,Bergese SD,Blackham KA,Stevens RD, Republished: Society for Neuroscience in Anesthesiology and Critical Care expert consensus statement: Anesthetic management of endovascular treatment for acute ischemic stroke. Stroke. 2014 Aug;     [PubMed PMID: 25070964]

Level 3 (low-level) evidence

[24]

Sare GM,Geeganage C,Bath PM, High blood pressure in acute ischaemic stroke--broadening therapeutic horizons. Cerebrovascular diseases (Basel, Switzerland). 2009;     [PubMed PMID: 19342846]


[25]

Leonardi-Bee J,Bath PM,Phillips SJ,Sandercock PA,IST Collaborative Group., Blood pressure and clinical outcomes in the International Stroke Trial. Stroke. 2002 May;     [PubMed PMID: 11988609]

Level 2 (mid-level) evidence

[26]

Jeong HG,Kim BJ,Kim H,Jung C,Han MK,Liebeskind DS,Bae HJ, Blood Pressure Drop and Penumbral Tissue Loss in Nonrecanalized Emergent Large Vessel Occlusion. Stroke. 2019 Oct;     [PubMed PMID: 31462194]


[27]

Tinoco CSL,Santos PMCD, [Anesthetic management of endovascular treatment for acute ischemic stroke: Influences on outcome and complications]. Brazilian journal of anesthesiology (Elsevier). 2018 Nov - Dec;     [PubMed PMID: 30195628]


[28]

Behme D,Gondecki L,Fiethen S,Kowoll A,Mpotsaris A,Weber W, Complications of mechanical thrombectomy for acute ischemic stroke-a retrospective single-center study of 176 consecutive cases. Neuroradiology. 2014 Jun;     [PubMed PMID: 24668181]

Level 2 (mid-level) evidence

[29]

Kurre W,Pérez MA,Horvath D,Schmid E,Bäzner H,Henkes H, Does mechanical thrombectomy in acute embolic stroke have long-term side effects on intracranial vessels? An angiographic follow-up study. Cardiovascular and interventional radiology. 2013 Jun;     [PubMed PMID: 23086452]

Level 2 (mid-level) evidence