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Anaesthetic and peri-operative management for thrombectomy procedures in stroke patients. Anaesth Crit Care Pain Med 2023; 42:101188. [PMID: 36599377 DOI: 10.1016/j.accpm.2022.101188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE To provide recommendations for the anaesthetic and peri-operative management for thrombectomy procedure in stroke patients DESIGN: A consensus committee of 15 experts issued from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation, SFAR), the Association of French-language Neuro-Anaesthetists (Association des Neuro-Anesthésistes Réanimateurs de Langue Francaise, ANARLF), the French Neuro-Vascular Society (Société Francaise de Neuro-Vasculaire, SFNV), the French Neuro-Radiology Society (Société Francaise de Neuro-Radiologie, SFNR) and the French Study Group on Haemostasis and Thrombosis (Groupe Français d'Études sur l'Hémostase et la Thrombose, GFHT) was convened, under the supervision of two expert coordinators from the SFAR and the ANARLF. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were required to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. METHODS Four fields were defined prior to the literature search: (1) Peri-procedural management, (2) Prevention and management of secondary brain injuries, (3) Management of antiplatelet and anticoagulant treatments, (4) Post-procedural management and orientation of the patient. Questions were formulated using the PICO format (Population, Intervention, Comparison, and Outcomes) and updated as needed. Analysis of the literature was then conducted and the recommendations were formulated according to the GRADE methodology. RESULTS The SFAR/ANARLF/SFNV/SFNR/GFHT guideline panel drew up 18 recommendations regarding anaesthetic management of mechanical thrombectomy procedures. Due to a lack of data in the literature allowing to conclude with high certainty on relevant clinical outcomes, the experts decided to formulate these guidelines as "Professional Practice Recommendations" (PPR) rather than "Formalized Expert Recommendations". After two rounds of rating and several amendments, a strong agreement was reached on 100% of the recommendations. No recommendation could be formulated for two questions. CONCLUSIONS Strong agreement among experts was reached to provide a sizable number of recommendations aimed at optimising anaesthetic management for thrombectomy in patients suffering from stroke.
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Maïer B, Gory B, Chabanne R, Tavernier B, Balanca B, Audibert G, Thion LA, Le Guen M, Geeraerts T, Calviere L, Degos V, Lapergue B, Richard S, Djarallah A, Mophawe O, Boursin P, Le Cossec C, Blanc R, Piotin M, Mazighi M, Gayat E. Effect of an individualized versus standard blood pressure management during mechanical thrombectomy for anterior ischemic stroke: the DETERMINE randomized controlled trial. Trials 2022; 23:598. [PMID: 35883180 PMCID: PMC9317065 DOI: 10.1186/s13063-022-06538-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hypotension and blood pressure (BP) variability during endovascular therapy (EVT) for acute ischemic stroke (AIS) due to an anterior large vessel occlusion (LVO) is associated with worse outcomes. However, the optimal BP threshold during EVT is still unknown given the lack of randomized controlled evidence. We designed the DETERMINE trial to assess whether an individualized BP management during EVT could achieve better functional outcomes compared to a standard BP management. Methods The DETERMINE trial is a multicenter, prospective, randomized, controlled, open-label, blinded endpoint clinical trial (PROBE design). AIS patients with a proximal anterior LVO are randomly assigned, in a 1:1 ratio, to an experimental arm in which mean arterial pressure (MAP) is maintained within 10% of the first MAP measured before EVT, or a control arm in which systolic BP (SBP) is maintained within 140–180 mm Hg until reperfusion is achieved or artery closure in case of EVT failure. The primary outcome is the rate of favorable functional outcomes, defined by a modified Rankin Scale (mRS) between 0 and 2 at 90 days. Secondary outcomes include excellent outcome and ordinal analysis of the mRS at 90 days, early neurological improvement at 24 h (National Institutes of Health Stroke Scale), final infarct volume, symptomatic intracranial hemorrhage rates, and all-cause mortality at 90 days. Overall, 432 patients will be included. Discussion DETERMINE will assess the clinical relevance of an individualized BP management before reperfusion compared to the one size fits all approach currently recommended by international guidelines. Trial registration ClinicalTrials.gov, NCT04352296. Registered on 20th April 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06538-9.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France. .,Université Paris-Cité, Paris, France.
| | - Benjamin Gory
- Diagnostic and Therapeutic Neuroradiology Department, CHRU-Nancy, Université de Lorraine, INSERM U124, Nancy, France
| | - Russell Chabanne
- Department of Anesthesia, Critical Care and Peri-Operative Medicine, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Benoît Tavernier
- Department of Anesthesia and Critical Care, University Hospital, Lille, F-59000, Lille, France.,Université Lille, ULR 2694 - METRICS, F-59000, Lille, France
| | - Baptiste Balanca
- Department of Neurological Anesthesiology and Intensive Care, Hospices Civils de Lyon, Hôpital Pierre Wertheimer, Groupement Hospitalier Est, 59 Boulevard Pinel, 69500, Bron, Lyon, France.,Lyon's Neuroscience Research Center, INSERM U1028/CNRS UMR 5292, Lyon 1 University, Lyon, France
| | | | - Laurie-Anne Thion
- Anesthesiology Department, Hôpital fondation A. de Rothschild, Paris, France
| | - Morgan Le Guen
- Anesthesiology Department, Foch Hospital, Suresnes, France
| | - Thomas Geeraerts
- Anesthesiology and Critical Care department, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Lionel Calviere
- Neurology Department, University Hospital of Toulouse, Toulouse, France
| | - Vincent Degos
- Department of Anesthesia, Critical Care and Peri-Operative Medicine, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France.,INSERM UMR 1141, Paris, France
| | | | - Sebastien Richard
- Neurology Department, CHRU-Nancy, Université de Lorraine, Nancy, France
| | - Azeddine Djarallah
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Ornellia Mophawe
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Perrine Boursin
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Chloé Le Cossec
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Raphael Blanc
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France.,Université Paris-Cité, Paris, France
| | - Etienne Gayat
- Université Paris-Cité, Paris, France.,Anesthesiology Department, Hôpital Lariboisière, Paris, France
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Farag E, Argalious M, Toth G. Stroke thrombectomy perioperative anesthetic and hemodynamic management. J Neurointerv Surg 2022; 15:483-487. [PMID: 35697516 DOI: 10.1136/neurintsurg-2021-018300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/21/2022] [Indexed: 11/04/2022]
Abstract
There is an ongoing debate about the optimal anesthetic and hemodynamic management of acute stoke patients with large vessel occlusion undergoing endovascular mechanical thrombectomy. Several prospective and retrospective analyses, and randomized controlled trials, attempted to address the challenges of using different anesthetic modalities in acute stroke patients requiring mechanical thrombectomy. We review the advantages and disadvantages of monitored anesthesia care, local anesthesia, conscious sedation, and general anesthesia, along with the relevance of hemodynamic management and perioperative oxygenation status in these complex patients.
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Affiliation(s)
- Ehab Farag
- Department of General Anesthesia, Anesthesiology and Pain Management Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Outcomes Research, Anesthesiology and Pain Management Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Maged Argalious
- Department of General Anesthesia, Anesthesiology and Pain Management Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Zhang X, Cui T, Zhu Q, Wang C, Wang A, Yang Y, Li S, Hu F, Wu B. Association of Blood Pressure Within 6 h After Endovascular Thrombectomy and Functional Outcomes in Ischemic Stroke Patients With Successful Recanalization. Front Neurol 2022; 13:860124. [PMID: 35493826 PMCID: PMC9046679 DOI: 10.3389/fneur.2022.860124] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/02/2022] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose Blood pressure in the days following endovascular thrombectomy (EVT) can influence functional outcomes of patients who have suffered an acute ischemic stroke, but whether the same is true of blood pressure during the first few hours after EVT is unclear. Methods Several blood pressure parameters were retrospectively analyzed in acute ischemic stroke patients who underwent EVT at West China Hospital from March 2016 to December 2019. Baseline blood pressure, speed of blood pressure reduction, postoperative blood pressure, degree of blood pressure reduction, and quality of blood pressure management were evaluated during the first 24 h after EVT. We explored whether these parameters during different time windows correlated significantly with patients' modified Rankin Scale (mRS) score at 90 days. Results Analysis of 163 patients showed that poor functional outcome (mRS scores 3–6) correlated significantly with higher postoperative blood pressure and worse blood pressure management during the first 6 h after EVT. Postoperative systolic blood pressure at 37 min after EVT was significantly higher in patients with poor outcome (141 mmHg) than in those with good outcome (mRS scores 0–2; 122 mmHg, p = 0.006), and systolic pressure >136 mmHg at this time point was associated with a significantly higher risk of poor outcome, before and after adjusting for other risk factors (adjusted OR 0.395, 95% CI 0.20–0.79). Conclusions Among acute ischemic patients who successfully undergo recanalization, adequate blood pressure management during the first 30–40 min after EVT may be important for ensuring good 90-day functional outcomes.
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Affiliation(s)
- Xuening Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Cui
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiange Zhu
- Second Department of Neurology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Changyi Wang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Anmo Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan Yang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Shucheng Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Fayun Hu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Fayun Hu
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Bo Wu
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Lyu M, Ventikos Y, Peach TW, Makalanda L, Bhogal P. Virtual Flow-T Stenting for Two Patient-Specific Bifurcation Aneurysms. Front Neurol 2021; 12:726980. [PMID: 34803876 PMCID: PMC8595090 DOI: 10.3389/fneur.2021.726980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/08/2021] [Indexed: 11/16/2022] Open
Abstract
The effective treatment of wide necked cerebral aneurysms located at vessel bifurcations (WNBAs) remains a significant challenge. Such aneurysm geometries have typically been approached with Y or T stenting configurations of stents and/or flow diverters, often with the addition of endovascular coils. In this study, two WNBAs were virtually treated by a novel T-stenting technique (Flow-T) with a number of braided stents and flow-diverter devices. Multiple possible device deployment configurations with varying device compression levels were tested, using fast-deployment algorithms, before a steady state computational hemodynamic simulation was conducted to examine the efficacy and performance of each scenario. The virtual fast deployment algorithm based on a linear and torsional spring analogy is used to accurately deploy nine stents in two WNBAs geometries. The devices expand from the distal to proximal side of the devices with respect to aneurysm sac. In the WNBAs modelled, all configurations of Flow-T device placement were shown to reduce factors linked with increased aneurysm rupture risk including aneurysm inflow jets and high aneurysm velocity, along with areas of flow impingement and elevated wall shear stress (WSS). The relative position of the flow-diverting device in the secondary daughter vessel in the Flow-T approach was found to have a negligible effect on overall effectiveness of the procedure in the two geometries considered. The level of interventionalist-applied compression in the braised stent that forms the other arm of the Flow-T approach was shown to impact the aneurysm inflow reduction and aneurysm flow pattern more substantially. In the Flow-T approach the relative position of the secondary daughter vessel flow-diverter device (the SVB) was found to have a negligible effect on inflow reduction, aneurysm flow pattern, or WSS distribution in both aneurysm geometries. This suggests that the device placement in this vessel may be of secondary importance. By contrast, substantially more variation in inflow reduction and aneurysm flow pattern was seen due to variations in braided stent (LVIS EVO or Baby Leo) compression at the aneurysm neck. As such we conclude that the success of a Flow-T procedure is primarily dictated by the level of compression that the interventionalist applies to the braided stent. Similar computationally predicted outcomes for both aneurysm geometries studied suggest that adjunct coiling approach taken in the clinical intervention of the second geometry may have been unnecessary for successful aneurysm isolation. Finally, the computational modelling framework proposed offers an effective planning platform for complex endovascular techniques, such as Flow-T, where the scope of device choice and combination is large and selecting the best strategy and device combination from several candidates is vital.
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Affiliation(s)
- Mengzhe Lyu
- Department of Mechanical Engineering, University College London (UCL), London, United Kingdom
| | - Yiannis Ventikos
- Department of Mechanical Engineering, University College London (UCL), London, United Kingdom.,School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Thomas W Peach
- Department of Mechanical Engineering, University College London (UCL), London, United Kingdom
| | - Levansri Makalanda
- Department of Interventional Neuroradiology, The Royal London Hospital, London, United Kingdom
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, United Kingdom
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