Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 2: Integrating and Applying Observational Reports and Randomized Clinical Trials

Bradley J Hindman; Franklin Dexter

doi:10.1213/ANE.0000000000004045

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Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 2: Integrating and Applying Observational Reports and Randomized Clinical Trials

Journal article

Open access

Peer reviewed

Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 2: Integrating and Applying Observational Reports and Randomized Clinical Trials

Bradley J Hindman and Franklin Dexter

Anesthesia and analgesia, Vol.128(4), pp.706-717

04/2019

DOI: 10.1213/ANE.0000000000004045

PMID: 30883416

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Abstract

The 2018 American Heart Association stroke care guidelines consider endovascular thrombectomy to be the standard of care for patients who have acute ischemic stroke in the anterior circulation when arterial puncture can be made: (1) within 6 h of symptom onset; or (2) within 6-24 h of symptom onset when specific eligibility criteria are satisfied. The aim of this 2-part review is to provide practical perspective on the clinical literature regarding anesthesia care of endovascular thrombectomy patients. In the preceding companion article (part 1), the rationale for rapid workflow and maintenance of blood pressure before reperfusion were reviewed. Also in part 1, the key patient and procedural factors determining endovascular thrombectomy effectiveness were identified. In this article (part 2), the observational literature regarding anesthesia for endovascular thrombectomy is summarized briefly, largely to identify its numerous biases, but also to develop hypotheses regarding sedation versus general anesthesia pertaining to workflow, hemodynamic management, and intra- and post-endovascular thrombectomy adverse events. These hypotheses underlie the conduct and outcome measures of 3 recent randomized clinical trials of sedation versus general anesthesia for endovascular thrombectomy. A meta-analysis of functional outcomes from these 3 trials show, when managed according to trial protocols, sedation and general anesthesia result in outcomes that are not significantly different. Details regarding anesthesia and hemodynamic management from these 3 trials are provided. This article concludes with a pragmatic approach to real-time anesthesia decision-making (sedation versus general anesthesia) and the goals and methods of acute phase anesthesia management of endovascular thrombectomy patients.

Blood Pressure

Decision Making

Anesthesia, General

Anesthetics - therapeutic use

Humans

Risk Factors

Emergency Treatment - methods

Treatment Outcome

Randomized Controlled Trials as Topic

Stroke - surgery

Endovascular Procedures - methods

Thrombectomy - methods

Observational Studies as Topic

Conscious Sedation

Hemodynamics

Intubation, Intratracheal

Brain Ischemia - surgery

Details

Title: Subtitle: Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 2: Integrating and Applying Observational Reports and Randomized Clinical Trials
Creators: Bradley J Hindman - From the Department of Anesthesia, The University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
Franklin Dexter
Resource Type: Journal article
Publication Details: Anesthesia and analgesia, Vol.128(4), pp.706-717
DOI: 10.1213/ANE.0000000000004045
PMID: 30883416
NLM abbreviation: Anesth Analg
ISSN: 0003-2999
eISSN: 1526-7598
Publisher: United States
Language: English
Date published: 04/2019
Academic Unit: Health Management and Policy; Anesthesia
Record Identifier: 9983806397102771

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