Management of Acute Ischemic Stroke–Specific Focus on Anesthetic Management for Mechanical Thrombectomy

Abstract

Acute ischemic stroke is a neurological emergency with a high likelihood of morbidity, mortality, and long-term disability. Modern stroke care involves multidisciplinary management by neurologists, radiologists, neurosurgeons, and anesthesiologists. Current American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend thrombolytic therapy with intravenous (IV) alteplase within the first 3–4.5 hours of initial stroke symptoms and endovascular mechanical thrombectomy within the first 16–24 hours depending on specific inclusion criteria. The anesthesia and critical care provider may become involved for airway management due to worsening neurologic status or to enable computerized tomography (CT) or magnetic resonance imaging (MRI) scanning, to facilitate mechanical thrombectomy, or to manage critical care of stroke patients. Existing data are unclear whether the mechanical thrombectomy procedure is best performed under general anesthesia or sedation. Retrospective cohort trials favor sedation over general anesthesia, but recent randomized controlled trials (RCT) neither suggest superiority nor inferiority of sedation over general anesthesia. Regardless of anesthesia type, a critical element of intraprocedural stroke care is tight blood pressure management. At different phases of stroke care, different blood pressure targets are recommended. This narrative review will focus on the anesthesia and critical care providers’ roles in the management of both perioperative stroke and acute ischemic stroke with a focus on anesthetic management for mechanical thrombectomy.

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

“…Based on the anesthesia types, it was confirmed that the use of general anesthesia caused a considerable delay. Recent studies have not been able to prove the superiority or inferiority of one anesthesia type over the other [ 1 ]. One may prefer general anesthesia, given the advantages of patient’s airway maintenance and ease of irritability control and the potential risks of conversion from local anesthesia to general anesthesia.…”

Acute ischemic stroke: practical considerations for anesthesiologists

“…GA is also recommended for patients who are vomiting or unable to cooperate. If MAC is the chosen technique, the procedural anesthesiologist should be ready to convert to GA if the patient experiences deteriorating neurological status, seizures, or procedural complications 28 . There is no evidence to support the use of any one agent over another through the use of shorter-acting agents may facilitate earlier neurological assessment after the procedure 26 …”

Anaesthesia for mechanical thrombectomy: a narrative review

“…There may be a role for depth of anaesthesia monitoring. It has been noted that doses of anaesthetic drugs used for both general anaesthesia and sedation during thrombectomy were uncharacteristically low compared with typical doses used in different circumstances [34]. As there is limited access to the patient, long extensions are recommended for infusions and fluid lines.…”