Monitored anesthesia care during mechanical thrombectomy for stroke: need for data-driven and individualized decisions

Abstract

BackgroundThe optimal anesthesia management for patients with stroke undergoing mechanical thrombectomy (MT) during the COVID-19 pandemic has become a matter of controversy. Some recent guidelines have favored general anesthesia (GA) in patients perceived as high risk for intraprocedural conversion from sedation to GA, including those with dominant hemispheric occlusions/aphasia or baseline National Institutes of Health Stroke Scale (NIHSS) score >15. We aim to identify the rate and predictors of conversion to GA during MT in a high-volume center where monitored anesthesia care (MAC) is the default modality.MethodsA retrospective review of a prospectively maintained MT database from January 2013 to July 2020 was undertaken. Analyses were conducted to identify the predictors of intraprocedural conversion to GA. In addition, we analyzed the GA conversion rates in subgroups of interest.ResultsAmong 1919 MT patients, 1681 (87.6%) started treatment under MAC (median age 65 years (IQR 55–76); baseline NIHSS 16 (IQR 11–21); 48.4% women). Of the 1677 eligible patients, 26 (1.6%) converted to GA including 1.4% (22/1615) with anterior and 6.5% (4/62) with posterior circulation strokes. The only predictor of GA conversion was posterior circulation stroke (OR 4.99, 95% CI 1.67 to 14.96, P=0.004). The conversion rates were numerically higher in right than in left hemispheric occlusions (1.6% vs 1.2%; OR 1.37, 95% CI 0.59 to 3.19, P=0.47) and in milder than in more severe strokes (NIHSS ≤15 vs >15: 2% vs 1.2%; OR 0.62, 95% CI 0.28 to 1.36, P=0.23).ConclusionsOur study showed that the overall rate of conversion from MAC to GA during MT was low (1.6%) and, while higher in posterior circulation strokes, it was not predicted by either hemispheric dominance or stroke severity. Caution should be given before changing clinical practice during moments of crisis.

General anesthesia vs procedural sedation for failed NeuroThrombectomy undergoing rescue stenting: intention to treat analysis

“…In our study, 11 out of 173 patients (6.4%) converted to GA of whom three patients (1.7%) were secondary to agitation or patient movement. This rate is comparable to a previously reported rate of 1.6%, with patient agitation being the most common reason 16. Several factors could cause patient movement and poor cooperation, for instance discomfort at the puncture site, a hot sensation due to injection of contrast material into the cerebral arteries and the pain associated with the traction of the blood vessels during catheter navigation, balloon inflation or stent deployment.…”

The prognostic significance of hyperdense middle cerebral artery sign in cardioembolic stroke patients undergoing mechanical thrombectomy:a multicenter observational clinical study

“…Liebeskind et al [30] identi ed that the presence of HMCAS was associated with thrombi primarily composed of red blood cells (RBCs) in their study on thrombus composition analysis in patients undergoing MT for acute MCA occlusion. Recent research has indicated that RBC-dominant thrombi are associated with shorter procedure times during MT [31,32]. In contrast, our study identi ed that HMCAS is linked to an increased number of thrombectomy passes.…”

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

“…As with any MAC case, conversion to general anesthesia with an invasive airway device is a possibility, and so proper preparation and resources must be in place for such an event. The rate of conversion from MAC to general anesthesia is relatively low, and no significant predictive factors have been reported [17]. There are, however, worse functional outcomes in those converted to general anesthesia compared with those remaining with MAC [18].…”