Anesthesia and Sedation Practices Among Neurointerventionalists during Acute Ischemic Stroke Endovascular Therapy

Abstract

Background and Purpose: Intra-arterial reperfusion therapies are expanding frontiers in acute ischemic stroke (AIS) management but there is considerable variability in clinical practice. The use of general anesthesia (GA) is one example. We aimed to better understand sedation practices in AIS. Methods: An online survey was distributed to the 68 active members of the Society of Vascular and Interventional Neurology (SVIN). Survey development was based on discussions at the SVIN Endovascular Stroke Round Table Meeting (Chicago, IL, 2008). The final survey contained 12 questions. Questions were developed as single and multiple-item responses; with an option for a free-text response. Results: There was a 72% survey response rate (N = 49/68). Respondents were interventional neurologists in practice 1–5 years (71.4%, N = 35). The mean (±SD) AIS interventions performed per year at the respondents’ institutions was 42.5 ± 25, median 35.0 (IQR 20, 60). The most frequent anesthesia type used was GA (anesthesia team), then conscious sedation (nurse administered), monitored anesthesia care (anesthesia team), and finally local analgesia alone. There was a preference for GA because of eliminating movement (65.3% of respondents; N = 32/49), perceived procedural safety (59.2%, N = 29/49), and improved procedural efficacy (42.9%, N = 21/49). However, cited limitations to GA included risk of time delay (69.4%, N = 34), of propagating cerebral ischemia due to hypoperfusion or other complications (28.6%, N = 14), and lack of adequate anesthesia workforce (20.4%, N = 7). Conclusions: The most frequent type of anesthesia used by Neurointerventionalists for AIS interventions is GA. Prior to making GA standard of care during AIS intervention, more data are needed about effects on clinical outcomes.

Clinical Impact of Ventilation Duration in Patients with Stroke Undergoing Interventional Treatment under General Anesthesia: The Shorter the Better?

“…[1][2][3][4][5] Most active members of the Society of Vascular and Interventional Neurology stated, in a recent survey, that they preferred general anesthesia over conscious sedation for recanalization treatment of acute ischemic stroke. 6 Patients with stroke are often noncompliant during endovascular procedures. 6 Conscious sedation and local anesthesia do not immobilize agitated patients and are not apt to secure the patient's airway and thus may lead to aspiration.…”

“…6 Patients with stroke are often noncompliant during endovascular procedures. 6 Conscious sedation and local anesthesia do not immobilize agitated patients and are not apt to secure the patient's airway and thus may lead to aspiration. 6,7 General anesthesia and intubation, however, allow complete immobilization and comfort of the patient, thereby allowing better image quality.…”

“…6 Conscious sedation and local anesthesia do not immobilize agitated patients and are not apt to secure the patient's airway and thus may lead to aspiration. 6,7 General anesthesia and intubation, however, allow complete immobilization and comfort of the patient, thereby allowing better image quality. 7,8 On the other hand, it is assumed that delays in door-to-puncture time, development of ventilatorassociated pneumonia, and ventilation-induced hypotension and hypocapnia may negatively influence clinical outcome in patients treated under GA. 9,10 In a recent retrospective study Ͼ500 patients who were treated under GA were matched with patients treated under conscious sedation.…”

Anesthetic Care for Acute Ischemic Stroke: Facts and Aspirations

“…It is important to point out that there is a preference toward GA amongst endovascular interventionalists (19). Therefore, the anesthesiologist is frequently requested to specifically provide GA. At centers where there is an algorithm for selecting GA patients, the sicker and more severely impaired patients will likely be selected for GA.…”

Endovaskuläre Therapie des akut ischämischen Schlaganfalls unter Analgosedierung im Vergleich zur Intubationsnarkose - Durchführbarkeit, periprozedurale Sicherheit, klinisches und radiologisches Outcome

“…Demgegenüber postulieren Brekenfeld et al, dass der Zeitverlust durch die Narkoseeinleitung durch bessere Rekanalisationsraten bei kürzerer Interventionsdauer und geringerer Komplikationsrate ausgeglichen wird [29]. Das Risiko von periprozeduralen Komplikationen durch unkontrollierte Bewegungen bei unkooperativen Patienten wird von verschiedenen Autoren als ein entscheidender Nachteil der Intervention in LA angesehen [11,29]. Dies konnten wir nicht bestätigen: Die Intervention musste in keinem Fall aufgrund von Bewegungsunruhe abgebrochen werden.…”