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Management of the Interventional Stroke Patient

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Julian Bösel
Julian Bösel
Julian Bösel
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Opinion statement: The acute treatment of major ischemic stroke has been revolutionized by strong and consistent evidence from multiple randomized trials. Endovascular treatment by mechanical thrombectomy will be increasingly chosen as an adjunctive or alternative to intravenous thrombolysis. To apply this form of stroke treatment is associated with the challenge of optimal periinterventional treatment. The patient has to be identified, counselled, prepared, monitored, cardiovascularly stabilized, possibly sedated and ventilated, and postprocedurally treated in the optimal way. However, most aspects of periinterventional treatment have as yet not been clarified and require prospective research. Among these, the question of general anesthesia vs conscious sedation has received most attention and may be the most crucial one. Based on a great amount of retrospective data, it appears reasonable to start the intervention under conscious sedation of the non-intubated patient with standby measures for emergent intubation, until prospective randomized trials have clarified that issue. Periinterventional management will significantly affect the success of recanalization.
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Curr Treat Options Neurol (2015) 17: 45
DOI 10.1007/s11940-015-0376-z
Critical Care Neurology (K Sheth, Section Editor)
Management
of the Interventional Stroke
Patient
Julian Bo¨sel, MD
Address
Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400,
69120, Heidelberg, Germany
Email: julian.boesel@med.uni-heidelberg.de
Published online: 21 September 2015
*Springer Science+Business Media New York 2015
This article is part of the Topical Collection on Critical Care Neurology
Keywords Endovascular treatment IThrombectomy IIntravenous thrombolysis IAcute ischemic stroke ILarge-vessel
occlusion IPeriinterventional stroke management IGeneral anesthesia IConscious sedation
Opinion statement
The acute treatment of major ischemic stroke has been revolutionized by strong and
consistent evidence from multiple randomized trials. Endovascular treatment by mechan-
ical thrombectomy will be increasingly chosen as an adjunctive or alternative to intrave-
nous thrombolysis. To apply this form of stroke treatment is associated with the challenge
of optimal periinterventional treatment. The patient has to be identified, counselled,
prepared, monitored, cardiovascularly stabilized, possibly sedated and ventilated, and
postprocedurally treated in the optimal way. However, most aspects of periinterventional
treatment have as yet not been clarified and require prospective research. Among these,
the question of general anesthesia vs conscious sedation has received most attention and
may be the most crucial one. Based on a great amount of retrospective data, it appears
reasonable to start the intervention under conscious sedation of the non-intubated
patient with standby measures for emergent intubation, until prospective randomized
trials have clarified that issue. Periinterventional management will significantly affect the
success of recanalization.
Introduction
Rapid recanalization of thrombotically or embolically
occluded brain vessels to achieve reperfusion has to be
the primary aim of acute stroke care [1]. Treating acute
ischemic stroke (AIS) by the current “gold standard”
intravenous thrombolysis (IVT) will only lead to recan-
alization in 30 % of patients if the stroke is caused by
occlusion of large, i.e., proximal, brain vessels, such as
the distal internal carotid artery (ICA), proximal middle
cerebral artery (MCA, segment M1, dominant or more
than one segment M2), the basilar artery (BA), or the
dominant or both vertebral arteries (VA) [1].
More than 30 years ago, the first endovascular treat-
ment of large-vessel AIS was performed and reported by
Zeumer, Hacke, and colleagues, who successfully treated
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Local anesthesia vs general anesthesia during endovascular therapy for acute posterior circulation stroke
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  • Jul 2020
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Objective The optimal anesthetic approach during endovascular therapy (EVT) in acute stroke patients remains an area of uncertainty. We investigated the impact of different anesthetic approaches on the outcome of posterior circulation stroke (PCS) patients undergoing EVT. Methods For this observational study, we enrolled consecutive PCS patients who underwent EVT from December 2012 to December 2018, and compared functional outcomes at 90 days as well as long-term follow-up in patients treated under local anesthesia (LA) versus general anesthesia (GA). Multivariable logistic regression and propensity score matched analyses were conducted. Results Among the 183 patients included in this study, 71 patients (38.8%) received LA and 112 patients (61.2%) received GA. Median modified Rankin Scale score at 90 days was 4 (IQR, 2–6) in both groups (P = .956). No significant differences in the rates of functional independence and mortality at 90 days as well as long-term follow-up post intervention were observed between the two groups, and Kaplan-Meier survival analysis showed comparable long-term survival probabilities. Safety outcomes (including procedure-related complications and serious adverse events) did not differ between these patients. The anesthetic approach was neither associated with functional independence nor associated with mortality. Propensity score matched analysis indicated similar results. Conclusions For PCS patients undergoing EVT, LA compared with GA does not seem to result in different functional outcomes and complications rates.
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General anesthesia vs local anesthesia during mechanical thrombectomy in acute ischemic stroke
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  • May 2019
Objective: To investigate the effect of general anesthesia (GA) on functional outcomes and complications rates in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT) compared to the use of local anesthesia (LA) at the puncture site. Methods: This observational study was based on a prospectively registry study. AIS patients underwent MT with GA or LA from January 2013 to October 2017 were included. The primary outcome was the modified Rankin Scale (mRS) score at 90 days post-intervention. Furthermore, we assessed the long-term outcome of these patients. Multivariable logistic regression analysis was conducted to adjust for confounders. Results: We enrolled 187 AIS patients in this study, patients in GA group had a similar mRS score compared to LA group at 90 days (2 [IQR, 1-4] vs 2.5 [IQR, 1-4], P = .917). No differences were found in the rates of functional independence (mRS 0-2), no or minimal disability (mRS 0-1), and mortality (mRS 6) between the 2 groups at 90 days post-intervention as well as long-term follow-up. The procedure-related complications and serious adverse events were similar between the LA group and GA group (P > .05 each). In multivariable analysis, GA use was not associated with functional outcomes. Conclusion: AIS patients who received GA during MT had similar functional outcomes and complications rates compared to patients received LA.
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Noninvasive Cerebral Oximetry during Endovascular Therapy for Acute Ischemic Stroke: An Observational Study
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Full-text available
  • Aug 2015
  • J CEREBR BLOOD F MET
Implementing endovascular stroke care often impedes neurologic assessment in patients who need sedation or general anesthesia. Cerebral near-infrared spectroscopy (NIRS) may help physicians monitor cerebral tissue viability, but data in hyperacute stroke patients receiving endovascular treatment are sparse. In this observational study, the NIRS index regional oxygen saturation (rSO2) was measured noninvasively before, during, and after endovascular therapy via bilateral forehead NIRS optodes. During the study period, 63 patients were monitored with NIRS; 43 qualified for analysis. Before recanalization, 10 distinct rSO2 decreases occurred in 11 patients with respect to time to intubation. During recanalization, two kinds of unilateral rSO2 changes occurred in the affected hemisphere: small peaks throughout the treatment (n=14, 32.6%) and sustained increases immediately after recanalization (n=2, 4.7%). Lower area under the curve 10% below baseline was associated with better reperfusion status (thrombolysis in cerebral infarction ≥ 2b, P=0.009). At the end of the intervention, lower interhemispheric rSO2 difference predicted death within 90 days (P=0.037). After the intervention, higher rSO2 variability predicted poor outcome (modified Rankin scale > 3, P=0.032). Our findings suggest that bi-channel rSO2-NIRS has potential for guiding neuroanesthesia and predicting outcome. To better monitor local revascularization, an improved stroke-specific set-up in future studies is necessary.Journal of Cerebral Blood Flow & Metabolism advance online publication, 5 August 2015; doi:10.1038/jcbfm.2015.181.
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Type of Anesthesia and Differences in Clinical Outcome After Intra-Arterial Treatment for Ischemic Stroke
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  • May 2015
Background and purpose: Intra-arterial treatment (IAT) in patients with acute ischemic stroke (AIS) can be performed with or without general anesthesia (GA). Previous studies suggested that IAT without the use of GA (non-GA) is associated with better clinical outcome. Nevertheless, no consensus exists about the anesthetic management during IAT of AIS patients. This study investigates the association between type of anesthesia and clinical outcome in a large cohort of patients with AIS treated with IAT. Methods: All consecutive patients with AIS of the anterior circulation who received IAT between 2002 and 2013 in 16 Dutch hospitals were included in the study. Primary outcome was functional outcome on the modified Rankin Scale at discharge. Difference in primary outcome between GA and non-GA was estimated using multiple ordinal regression analysis, adjusting for age, stroke severity, occlusion of the internal carotid artery terminus, previous stroke, atrial fibrillation, and diabetes mellitus. Results: Three hundred forty-eight patients were included in the analysis; 70 patients received GA and 278 patients did not receive GA. Non-GA was significantly associated with good clinical outcome (odds ratio 2.1, 95% confidence interval 1.02-4.31). After adjusting for prespecified prognostic factors, the point estimate remained similar; statistical significance, however, was lost (odds ratio 1.9, 95% confidence interval 0.89-4.24). Conclusions: Our study suggests that patients with AIS of the anterior circulation undergoing IAT without GA have a higher probability of good clinical outcome compared with patients treated with general anesthesia.
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Imaging in Endovascular Stroke Trials
Article
  • Jul 2015
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Ischemic stroke remains a leading cause of death and disability worldwide. Various endovascular trials have addressed clinical outcomes without elucidating the impact of imaging studies in patient selection. The success of recent endovascular trials was bolstered by the use of advanced imaging techniques for optimal selection of reperfusion candidates. This seminal juncture in the history of stroke trials warrants further consideration on the use of imaging to guide future refinements in the treatment of acute stroke. In this article, we systematically review the imaging methodology and key facets used in all published endovascular stroke trials to date, discuss the success of recent trials using latest advanced imaging techniques and focus on the importance of imaging studies for future patient selection. Copyright © 2015 by the American Society of Neuroimaging.
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2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment
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  • Jun 2015
  • STROKE
The aim of this guideline is to provide a focused update of the current recommendations for the endovascular treatment of acute ischemic stroke. Where there is overlap, the recommendations made here supersede those of previous guidelines. This focused update analyzes results from 8 randomized clinical trials of endovascular treatment and other relevant data published since 2013. It is not intended to be a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that justifies changes in current recommendations. Members of the writing committee were appointed by the American Heart Association/American Stroke Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association/American Stroke Association Manuscript Oversight Committee (MOC). Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statement Oversight Committee and Stroke Council Leadership Committee. Evidence-based guidelines are presented for the selection of patients with acute ischemic stroke for endovascular treatment, the endovascular procedure and for systems of care to facilitate endovascular treatment. Certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke. Systems of care should be organized to facilitate the delivery of this care. © 2015 American Heart Association, Inc.
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Endovascular stent thrombectomy: The new standard of care for large vessel ischaemic stroke
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Results of initial randomised trials of endovascular treatment for ischaemic stroke, published in 2013, were neutral but limited by the selection criteria used, early-generation devices with modest efficacy, non-consecutive enrolment, and treatment delays. In the past year, six positive trials of endovascular thrombectomy for ischaemic stroke have provided level 1 evidence for improved patient outcome compared with standard care. In most patients, thrombectomy was performed in addition to thrombolysis with intravenous alteplase, but benefits were also reported in patients ineligible for alteplase treatment. Despite differences in the details of eligibility requirements, all these trials required proof of major vessel occlusion on non-invasive imaging and most used some imaging technique to exclude patients with a large area of irreversibly injured brain tissue. The results indicate that modern thrombectomy devices achieve faster and more complete reperfusion than do older devices, leading to improved clinical outcomes compared with intravenous alteplase alone. The number needed to treat to achieve one additional patient with independent functional outcome was in the range of 3·2-7·1 and, in most patients, was in addition to the substantial efficacy of intravenous alteplase. No major safety concerns were noted, with low rates of procedural complications and no increase in symptomatic intracerebral haemorrhage. WHERE NEXT?: Thrombectomy benefits patients across a range of ages and levels of clinical severity. A planned meta-analysis of individual patient data might clarify effects in under-represented subgroups, such as those with mild initial stroke severity or elderly patients. Imaging-based selection, used in some of the recent trials to exclude patients with large areas of irreversible brain injury, probably contributed to the proportion of patients with favourable outcomes. The challenge is how best to implement imaging in clinical practice to maximise benefit for the entire population and to avoid exclusion of patients with smaller yet clinically important potential to benefit. Although favourable imaging identifies patients who might benefit despite long delays from symptom onset to treatment, the proportion of patients with favourable imaging decreases with time. Health systems therefore need to be reorganised to deliver treatment as quickly as possible to maximise benefits. On the basis of available trial data, intravenous alteplase remains the initial treatment for all eligible patients within 4·5 h of stroke symptom onset. Those patients with major vessel occlusion should, in parallel, proceed to endovascular thrombectomy immediately rather than waiting for an assessment of response to alteplase, because minimising time to reperfusion is the ultimate aim of treatment. Copyright © 2015 Elsevier Ltd. All rights reserved.
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