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Yamamoto W, Hamada T, Suzuki J, Matsuoka Y, Omori-Miyake M, Kuwahara M, Matsumoto A, Nomura S, Konishi A, Yorozuya T, Yamashita M. Suppressive effect of the anesthetic propofol on the T cell function and T cell-dependent immune responses. Sci Rep 2024; 14:19337. [PMID: 39164311 PMCID: PMC11336218 DOI: 10.1038/s41598-024-69987-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 08/12/2024] [Indexed: 08/22/2024] Open
Abstract
General anesthesia is thought to suppress the immune system and negatively affect postoperative infection and the long-term prognosis of cancer. However, the mechanism underlying immunosuppression induced by general anesthetics remains unclear. In this study, we focused on propofol, which is widely used for sedation under general anesthesia and intensive care and examined its effects on the T cell function and T cell-dependent immune responses. We found that propofol suppressed T cell glycolytic metabolism, differentiation into effector T cells, and cytokine production by effector T cells. CD8 T cells activated and differentiated into effector cells in the presence of propofol in vitro showed reduced antitumor activity. Furthermore, propofol treatment suppressed the increase in the number of antigen-specific CD8 T cells during Listeria infection. In contrast, the administration of propofol improved inflammatory conditions in mouse models of inflammatory diseases, such as OVA-induced allergic airway inflammation, hapten-induced contact dermatitis, and experimental allergic encephalomyelitis. These results suggest that propofol may reduce tumor and infectious immunity by suppressing the T cell function and T cell-dependent immune responses while improving the pathogenesis and prognosis of chronic inflammatory diseases by suppressing inflammation.
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Affiliation(s)
- Waichi Yamamoto
- Department of Anesthesia and Perioperative Medicine, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
- Department of Immunology, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Taisuke Hamada
- Department of Anesthesia and Perioperative Medicine, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
- Department of Immunology, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Junpei Suzuki
- Department of Immunology, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Yuko Matsuoka
- Translational Research Center, Ehime University Hospital, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Miyuki Omori-Miyake
- Department of Infections and Host Defenses, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Makoto Kuwahara
- Department of Immunology, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Akira Matsumoto
- Department of Immunology, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Shunsuke Nomura
- Department of Immuno-Drug Chemistry, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Amane Konishi
- Department of Anesthesia and Perioperative Medicine, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Toshihiro Yorozuya
- Department of Anesthesia and Perioperative Medicine, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Masakatsu Yamashita
- Department of Immunology, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan.
- Translational Research Center, Ehime University Hospital, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan.
- Department of Infections and Host Defenses, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan.
- Department of Immuno-Drug Chemistry, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan.
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2
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Jia Y, Feng Y, Ma Y, Feng G, Xu N, Li M, Liu M, Fan Z, Wang T. Type of anesthesia for endovascular therapy in acute ischemic stroke: A literature review and meta-analysis. Int J Stroke 2024; 19:735-746. [PMID: 38234158 DOI: 10.1177/17474930241228956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) has been proven as the standard treatment for acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). However, the ideal anesthetic strategy during EVT still remains unclear. Therefore, this systematic review and meta-analysis aimed to determine the optimal anesthetic modality for patients with AIS undergoing EVT based on current randomized controlled trials (RCTs). METHODS The databases Medline (via PubMed), EMBASE, Web of Science, and the Cochrane Library were searched for RCTs comparing general anesthesia (GA) and conscious sedation (CS) in AIS patients undergoing EVT. The primary outcome was a favorable functional outcome at 90 days postintervention. Data analysis was conducted using the Review Manager software (RevMan V.5.3). RESULTS Eight RCTs involving 1199 patients were included. There was no significant difference between GA and CS group in the rate of functional independence (risk ratio (RR) = 1.10, 95% confidence interval (CI) = 0.96 to 1.25; p = 0.17; I2 = 30%). Compared with the CS group, the GA group attained a higher successful recanalization rate (RR = 1.14, 95% CI = 1.08 to 1.20; p < 0.00001; I2 = 17%). In addition, patients in the GA were associated with a higher rate of hypotension (RR = 1.87, 95% CI = 1.44 to 2.41; p < 0.00001; I2 = 66%) and a higher incidence of pneumonia (RR = 1.38, 95% CI = 1.05 to 1.8; p = 0.02; I2 = 37%). CONCLUSION For AIS patients receiving EVT, the choice of anesthetic modality did not influence the 3-month neurological outcome while GA is superior to CS in terms of successful reperfusion rate. Moreover, the patients in the GA group were at a higher risk of developing hypotension and pneumonia. Further studies are required to provide more sufficient evidence.
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Affiliation(s)
- Yitong Jia
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yao Feng
- Department of Neurology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yanhui Ma
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guang Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Na Xu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Meng Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Miao Liu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhen Fan
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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3
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Franx B, Dijkhuizen RM, Dippel DWJ. Acute Ischemic Stroke in the Clinic and the Laboratory: Targets for Translational Research. Neuroscience 2024; 550:114-124. [PMID: 38670254 DOI: 10.1016/j.neuroscience.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/26/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
Ischemic stroke research has enabled significant advancements in diagnosis, treatment, and management of this debilitating disease, yet challenges remain standing in the way of better patient prognoses. In this narrative review, a fictional case illustrates challenges and uncertainties that medical professionals still face - penumbra identification, lack of neuroprotective agents, side-effects of tissue plasminogen activator, dearth of molecular biomarkers, incomplete microvascular reperfusion or no-reflow, post-recanalization hyperperfusion, blood pressure management and procedural anesthetic effects. The current state of the field is broadly reviewed per topic, with the aim to introduce a broad audience (scientist and clinician alike) to recent successes in translational stroke research and pending scientific queries that are tractable for preclinical assessment. Opportunities for co-operation between clinical and experimental stroke experts are highlighted to increase the size and frequency of strides the field makes to improve our understanding of this disease and ways of treating it.
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Affiliation(s)
- Bart Franx
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Rick M Dijkhuizen
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Diederik W J Dippel
- Stroke Center, Dept of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Sharma S, Dube SK, Esmail T, Hoefnagel AL, Jangra K, Mejia-Mantilla J, Shiferaw AA, De Sloovere V, Wright D, Lele AV, Blacker SN. Assessing Practice Variation of Anesthetic Management for Endovascular Thrombectomy in Acute Ischemic Stroke: A Comprehensive Multicenter Survey. J Neurosurg Anesthesiol 2024:00008506-990000000-00117. [PMID: 38973631 DOI: 10.1097/ana.0000000000000976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/27/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE This study explored the current global landscape of periprocedural care of acute ischemic stroke patients undergoing endovascular thrombectomy (EVT). METHODS An anonymous, 54-question electronic survey was sent to 354 recipients in hospitals worldwide. The responses were stratified by World Bank country income level into high-income (HICs) and low/middle-income (LMICs) countries. RESULTS A total of 354 survey invitations were issued. Two hundred twenty-three respondents started the survey, and 87 fully completed surveys were obtained from centers in which anesthesiologists were routinely involved in EVT care (38 in HICs; 49 in LMICs). Respondents from 35 (92.1%) HICs and 14 (28.6%) LMICs reported that their centers performed >50 EVTs annually. Respondents from both HICs and LMICs reported low rates of anesthesiologist involvement in pre-EVT care, though a communication system was in place in 100% of HIC centers and 85.7% of LMIC centers to inform anesthesiologists about potential EVTs. Respondents from 71.1% of HIC centers and 51% of LMIC centers reported following a published guideline during EVT management, though the use of cognitive aids was low in both (28.9% and 24.5% in HICs and LMICs, respectively). Variability in multiple areas of practice, including choice of anesthetic techniques, monitoring and management of physiological variables during EVT, and monitoring during intrahospital transport, were reported. Quality metrics were rarely tracked or reported to the anesthesiology teams. CONCLUSIONS This study demonstrated variability in anesthesiology involvement and in clinical care during and after EVT. Centers may consider routinely involving anesthesiologists in pre-EVT care, using evidence-based recommendations for EVT management, and tracking adherence to published guidelines and other quality metrics.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Surya Kumar Dube
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Tariq Esmail
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, ON, Canada
| | - Amie L Hoefnagel
- Department of Anesthesiology, University of Florida College of Medicine, Jacksonville, FL
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, Postgraduate Institute, Chandigarh, India
| | - Jorge Mejia-Mantilla
- Department of Critical Care Medicine, Fundación Valle del Lili, University Hospital, Cali, Colombia
| | | | - Veerle De Sloovere
- Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - David Wright
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Abhijit Vijay Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
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5
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Ordies S, De Brauwer T, De Beule T, Van Poucke S, Bekelaar K, Van Bylen B, Mesotten D. The effect of anesthesia on hemodynamics and outcome of patients undergoing thrombectomy after acute ischemic stroke: a retrospective analysis. Acta Neurol Belg 2024; 124:523-531. [PMID: 37857938 DOI: 10.1007/s13760-023-02399-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Anesthesia during thrombectomy remains a matter of debate. We retrospectively investigated the influence of intraprocedural blood pressure and type of anaesthetic agent on 3-month functional outcome and mortality in stroke patients undergoing mechanical thrombectomy under general anesthesia in a single center study. METHODS All patients suffering from stroke who presented between January 2019 and July 2021 at Ziekenhuis Oost-Limburg Genk, Belgium and who received thrombectomy were included. Patient's characteristics and outcome data had been collected for benchmarking. Detailed perioperative data were exported from the electronic anesthesia records and clinically validated. Patients were stratified by peri-operative presence of hypotension (MAP < 65 mmHg at any time point) versus no-hypotension (MAP ≥ 65 mmHg). RESULTS All 98 patients received mechanical thrombectomy under general anesthesia. Thirty-six percent (n = 35) was hypotensive peri-operatively at any time point. Proportion of sevoflurane use was higher in non-hypotensive patients compared to hypotensive patients (73% (n = 45) vs. 51% (n = 18), p = 0.04). Peri-operative use of vasopressors was higher in the hypotensive group compared to non-hypotensive (88% (n = 30) vs. 63% (n = 39), p = 0.008). Proportion of patients with good functional outcome at 3 months (mRS 0-2) was higher in non-hypotensive patients compared to hypotensive patients 44% (n = 27) vs. 24% (n = 8), p < 0.05. 90-day mortality was lower in non-hypotensive patients compared to hypotensive patients 21% (n = 13) vs. 43% (n = 15), (p = 0.02). CONCLUSION Patients who are hypotensive at any given time during thrombectomy under general anesthesia may have worse neurological outcome compared to non-hypotensive patients. The best anaesthetic management for mechanical thrombectomy needs to be clarified prospectively in large multicenter studies.
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Affiliation(s)
- Sofie Ordies
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium.
- University Hospitals Leuven, Leuven, Belgium.
| | - Thomas De Brauwer
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
- University Hospitals Leuven, Leuven, Belgium
| | - Tom De Beule
- Department of Neuroradiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Sven Van Poucke
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Kim Bekelaar
- Department of Neurology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ben Van Bylen
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter Mesotten
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine and Life Sciences, University of Hasselt, Diepenbeek, Belgium
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6
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Franx BAA, van Tilborg GAF, van der Toorn A, van Heijningen CL, Dippel DWJ, van der Schaaf IC, Dijkhuizen RM. Propofol anesthesia improves stroke outcomes over isoflurane anesthesia-a longitudinal multiparametric MRI study in a rodent model of transient middle cerebral artery occlusion. Front Neurol 2024; 15:1332791. [PMID: 38414549 PMCID: PMC10897009 DOI: 10.3389/fneur.2024.1332791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/24/2024] [Indexed: 02/29/2024] Open
Abstract
General anesthesia is routinely used in endovascular thrombectomy procedures, for which volatile gas and/or intravenous propofol are recommended. Emerging evidence suggests propofol may have superior effects on disability and/or mortality rates, but a mode-of-action underlying these class-specific effects remains unknown. Here, a moderate isoflurane or propofol dosage on experimental stroke outcomes was retrospectively compared using serial multiparametric MRI and behavioral testing. Adult male rats (N = 26) were subjected to 90-min filament-induced transient middle cerebral artery occlusion. Diffusion-, T2- and perfusion-weighted MRI was performed during occlusion, 0.5 h after recanalization, and four days into the subacute phase. Sequels of ischemic damage-blood-brain barrier integrity, cerebrovascular reactivity and sensorimotor functioning-were assessed after four days. While size and severity of ischemia was comparable between groups during occlusion, isoflurane anesthesia was associated with larger lesion sizes and worsened sensorimotor functioning at follow-up. MRI markers indicated that cytotoxic edema persisted locally in the isoflurane group early after recanalization, coinciding with burgeoning vasogenic edema. At follow-up, sequels of ischemia were further aggravated in the post-ischemic lesion, manifesting as increased blood-brain barrier leakage, cerebrovascular paralysis and cerebral hyperperfusion. These findings shed new light on how isoflurane, and possibly similar volatile agents, associate with persisting injurious processes after recanalization that contribute to suboptimal treatment outcome.
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Affiliation(s)
- Bart A. A. Franx
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Geralda A. F. van Tilborg
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Annette van der Toorn
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Caroline L. van Heijningen
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | | | | | - Rick M. Dijkhuizen
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
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Ni X, Yu X, Ye Q, Su X, Shen S. Desflurane improves electrical activity of neurons and alleviates oxygen-glucose deprivation-induced neuronal injury by activating the Kcna1-dependent Kv1.1 channel. Exp Brain Res 2024; 242:477-490. [PMID: 38184806 DOI: 10.1007/s00221-023-06764-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/11/2023] [Indexed: 01/08/2024]
Abstract
Several volatile anesthetics have presented neuroprotective functions in ischemic injury. This study investigates the effect of desflurane (Des) on neurons following oxygen-glucose deprivation (OGD) challenge and explores the underpinning mechanism. Mouse neurons HT22 were subjected to OGD, which significantly reduced cell viability, increased lactate dehydrogenase release, and promoted cell apoptosis. In addition, the OGD condition increased oxidative stress in HT22 cells, as manifested by increased ROS and MDA contents, decreased SOD activity and GSH/GSSG ratio, and reduced nuclear protein level of Nrf2. Notably, the oxidative stress and neuronal apoptosis were substantially blocked by Des treatment. Bioinformatics suggested potassium voltage-gated channel subfamily A member 1 (Kcna1) as a target of Des. Indeed, the Kcna1 expression in HT22 cells was decreased by OGD but restored by Des treatment. Artificial knockdown of Kcna1 negated the neuroprotective effects of Des. By upregulating Kcna1, Des activated the Kv1.1 channel, therefore enhancing K+ currents and inducing neuronal repolarization. Pharmacological inhibition of the Kv1.1 channel reversed the protective effects of Des against OGD-induced injury. Collectively, this study demonstrates that Des improves electrical activity of neurons and alleviates OGD-induced neuronal injury by activating the Kcna1-dependent Kv1.1 channel.
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Affiliation(s)
- Xiaolei Ni
- Department of Anesthesiology and Perioperative Medicine, The Affiliated Suqian First People's Hospital of Nanjing Medical University, No. 120, Suzhi Road, Sucheng District, Suqian, 223800, Jiangsu, People's Republic of China
| | - Xiaoyan Yu
- Department of Anesthesiology and Perioperative Medicine, The Affiliated Suqian First People's Hospital of Nanjing Medical University, No. 120, Suzhi Road, Sucheng District, Suqian, 223800, Jiangsu, People's Republic of China
| | - Qingqing Ye
- Department of Anesthesiology and Perioperative Medicine, The Affiliated Suqian First People's Hospital of Nanjing Medical University, No. 120, Suzhi Road, Sucheng District, Suqian, 223800, Jiangsu, People's Republic of China
| | - Xiaohu Su
- Department of Anesthesiology and Perioperative Medicine, The Affiliated Suqian First People's Hospital of Nanjing Medical University, No. 120, Suzhi Road, Sucheng District, Suqian, 223800, Jiangsu, People's Republic of China
| | - Shuai Shen
- Department of Anesthesiology and Perioperative Medicine, The Affiliated Suqian First People's Hospital of Nanjing Medical University, No. 120, Suzhi Road, Sucheng District, Suqian, 223800, Jiangsu, People's Republic of China.
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Diprose WK, Rao A, Ghate K, Dyer Z, Campbell D, Almekhlafi M, Barber PA. Penumbral cooling in ischemic stroke with intraarterial, intravenous or active conductive head cooling: A thermal modeling study. J Cereb Blood Flow Metab 2024; 44:66-76. [PMID: 37734834 PMCID: PMC10905634 DOI: 10.1177/0271678x231203025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 09/23/2023]
Abstract
In ischemic stroke, selectively cooling the ischemic penumbra might lead to neuroprotection while avoiding systemic complications. Because penumbral tissue has reduced cerebral blood flow and in vivo brain temperature measurement remains challenging, the effect of different methods of therapeutic hypothermia on penumbral temperature are unknown. We used the COMSOL Multiphysics® software to model a range of cases of therapeutic hypothermia in ischemic stroke. Four ischemic stroke models were developed with ischemic core and/or penumbra volumes between 33-300 mL. Four experiments were performed on each model, including no cooling, and intraarterial, intravenous, and active conductive head cooling. The steady-state temperature of the non-ischemic brain, ischemic penumbra, and ischemic core without cooling was 37.3 °C, 37.5-37.8 °C, and 38.9-39.4 °C respectively. Intraarterial, intravenous and active conductive head cooling reduced non-ischemic brain temperature by 4.3 °C, 2.1 °C, and 0.7-0.8 °C respectively. Intraarterial, intravenous and head cooling reduced the temperature of the ischemic penumbra by 3.9-4.3 °C, 1.9-2.1 °C, and 1.2-3.4 °C respectively. Active conductive head cooling was the only method to selectively reduce penumbral temperature. Clinical studies that measure brain temperature in ischemic stroke patients undergoing therapeutic hypothermia are required to validate these hypothesis-generating findings.
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Affiliation(s)
- William K Diprose
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Avinash Rao
- Department of Engineering, Victoria University of Wellington, Wellington, New Zealand
| | - Kaustubha Ghate
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Zoe Dyer
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Doug Campbell
- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | | | - P Alan Barber
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
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9
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Crimmins D, Ryan E, Shah D, Lwin TN, Ayotte S, Redmond K, Highton D. The Effect of Anesthetic Agent and Mean Arterial Pressure on Functional Outcome After General Anesthesia for Endovascular Thrombectomy. J Neurosurg Anesthesiol 2024; 36:29-36. [PMID: 36477404 DOI: 10.1097/ana.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 10/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The optimal general anesthetic (GA) technique for stroke patients undergoing endovascular thrombectomy (ET) is unclear. We compared favorable outcomes and mortality in patients receiving propofol or volatile GA during ET and assessed associations between mean arterial pressure (MAP) and outcome. METHODS Ninety-three patients with anterior circulation stroke who received propofol or volatile GA during ET between February 2015 and February 2018 were included in this retrospective study. Ninety-day modified Rankin scores were compared and mortality was adjusted for intravenous thrombolysis and diabetes. We performed ordinal logistic regression analyses containing MAP time/exposure thresholds. RESULTS There was no difference in the rate of favorable outcome (modified Rankin scores 0-2) in the volatile and propofol groups (48.8% vs. 55.8%, respectively; P =0.5). Ninety-day mortality was lower in patients receiving propofol (11.5%) than in those receiving volatile GA (29.3%) (odds ratio, 0.32; 95% confidence interval, 0.11 to 0.94; P =0.03); this mortality benefit was greater in patients that did not receive intravenous thrombolysis before ET (odds ratio for survival, 6; 95% confidence interval, 1.13 to 31.74). There was no difference in MAP between groups and a (nonsignificant) trend towards the benefit of MAP <90 mm Hg but not <70 mm Hg. CONCLUSIONS Favorable outcome rates were similar in stroke patients receiving propofol or volatile GA during ET. Propofol was associated with lower mortality, an effect magnified in patients that did not receive intravenous thrombolysis. MAP time/exposure thresholds were associated with outcome but independent of the anesthetic agent. Our data suggest that a difference in outcome related to an anesthetic agent may exist; this hypothesis needs to be tested in a prospective study.
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Affiliation(s)
| | - Elizabeth Ryan
- Centre for Health Services Research, Faculty of Medicine
- QCIF Facility for Advanced Bioinformatics, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | | | | | - Steven Ayotte
- Princess Alexandra Hospital, Southside Clinical Unit
| | | | - David Highton
- Princess Alexandra Hospital, Southside Clinical Unit
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10
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Scheid S, Goebel U, Ulbrich F. Neuroprotection Is in the Air-Inhaled Gases on Their Way to the Neurons. Cells 2023; 12:2480. [PMID: 37887324 PMCID: PMC10605176 DOI: 10.3390/cells12202480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/29/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023] Open
Abstract
Cerebral injury is a leading cause of long-term disability and mortality. Common causes include major cardiovascular events, such as cardiac arrest, ischemic stroke, and subarachnoid hemorrhage, traumatic brain injury, and neurodegenerative as well as neuroinflammatory disorders. Despite improvements in pharmacological and interventional treatment options, due to the brain's limited regeneration potential, survival is often associated with the impairment of crucial functions that lead to occupational inability and enormous economic burden. For decades, researchers have therefore been investigating adjuvant therapeutic options to alleviate neuronal cell death. Although promising in preclinical studies, a huge variety of drugs thought to provide neuroprotective effects failed in clinical trials. However, utilizing medical gases, noble gases, and gaseous molecules as supportive treatment options may offer new perspectives for patients suffering neuronal damage. This review provides an overview of current research, potentials and mechanisms of these substances as a promising therapeutic alternative for the treatment of cerebral injury.
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Affiliation(s)
- Stefanie Scheid
- Department of Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care Medicine, St. Franziskus-Hospital, 48145 Muenster, Germany;
| | - Felix Ulbrich
- Department of Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
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11
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Zhang T, Thakkar P, Emans TW, Fong D, Thampi S, Felippe ISA, Barrett CJ, Billing R, Campbell D, McBryde FD. Combined Arterial Hypertension and Ischemic Stroke Exaggerate Anesthesia-Related Hypotension and Cerebral Oxygenation Deficits: A Preclinical Study. Anesth Analg 2023; 137:440-450. [PMID: 36730724 DOI: 10.1213/ane.0000000000006263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intraoperative arterial hypotension (IOH) is a common side effect of general anesthesia (GA), associated with poor outcomes in ischemic stroke. While IOH is more prevalent with hypertension, it is unknown whether IOH may differ when GA is induced during ischemic stroke, versus other clinical settings. This is important given that many stroke patients receive GA for endovascular thrombectomy. METHODS We evaluate the cardiovascular responses to volatile GA (isoflurane in 100% o2 ) before and during middle cerebral artery occlusion stroke in rats instrumented to record blood pressure (BP) and cerebral tissue oxygenation (p o2 ) in the projected penumbra, in clinically relevant cohorts of normotensive (Wistar rat, n = 10), treated hypertensive (spontaneously hypertensive [SH] + enalapril, n = 12), and untreated hypertensive (SH rat, n = 12). RESULTS During baseline induction of GA, IOH was similar in normotensive, treated hypertensive, and untreated hypertensive rats during the induction phase (first 10 minutes) (-24 ± 15 vs -28 ± 22 vs -48 ± 24 mm Hg; P > .05) and across the procedure (-24 ± 13 vs -30 ± 35 vs -39 ± 27 mm Hg; P > .05). Despite the BP reduction, cerebral p o2 increased by ~50% in all groups during the procedure. When inducing GA after 2 hours, all stroke groups showed a greater magnitude IOH compared to baseline GA induction, with larger falls in treated (-79 ± 24 mm Hg; P = .0202) and untreated(-105 ± 43 mm Hg; P < .001) hypertensive rats versus normotensives (-49 ± 21 mm Hg). This was accompanied by smaller increases in cerebral p o2 in normotensive rats (19% ± 32%; P = .0144 versus no-stroke); but a decrease in cerebral p o2 in treated (-11% ± 19%; P = .0048) and untreated (-12% ± 15%; P = .0003) hypertensive rats. Sham animals (normotensive and hypertensive) showed similar magnitude and pattern of IOH when induced with GA before and after sham procedure. CONCLUSIONS Our findings are the first demonstration that ischemic stroke per se increases the severity of IOH, particularly when combined with a prior history of hypertension; this combination appears to compromise penumbral perfusion.
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Affiliation(s)
- Tracy Zhang
- From the Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Pratik Thakkar
- From the Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Tonja W Emans
- From the Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Debra Fong
- From the Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Suma Thampi
- From the Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Igor S A Felippe
- From the Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Carolyn J Barrett
- From the Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Robyn Billing
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Douglas Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Fiona D McBryde
- From the Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
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12
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Vinay B, Manohara N, Lobo FA, Lee-St John T, Lamperti M. Inhalational versus Intravenous General Anesthesia for mechanical thrombectomy for stroke: A single centre retrospective study. Clin Neurol Neurosurg 2023; 229:107719. [PMID: 37084650 DOI: 10.1016/j.clineuro.2023.107719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/27/2023] [Accepted: 04/16/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND When general anesthesia is used for endovascular thrombectomy (EVT) for acute ischemic stroke (AIS), the choice of anesthetic agents for maintenance remains inconclusive. The different effects of intravenous anesthetic and volatiles agents on cerebral hemodynamics are known and may explain differences in outcomes of patients with cerebral pathologies exposed to the different anesthetic modalities. In this single institutional retrospective study, we assessed the impact of total intravenous (TIVA) and inhalational anesthesia on outcomes after EVT. METHODS We conducted a retrospective analysis of all patients ≥ 18 years who underwent EVT for AIS of the anterior or posterior circulation under general anesthesia. Baseline patient characteristics, anesthetic agents, intra operative hemodynamics, stroke characteristics, time intervals and clinical outcome data were collected and analyzed. RESULTS The study cohort consisted of 191 patients. After excluding 76 patients who were lost to follow up at 90 days, 51 patients received inhalational anesthesia and 64 patients who received TIVA were analyzed. The clinical characteristics between the groups were comparable. Multivariate logistic regression analysis of outcome measures for TIVA versus inhalational anesthesia showed significantly increased odds of good functional outcome (mRS 0-2) at 90 days (adjusted odds ratio, 3.24; 95% CI, 1.25-8.36; p = 0.015) and a non-significant trend towards decreased mortality (adjusted odds ratio, 0.73; CI, 0.15-3.6; p = 0.70). CONCLUSION Patients who had TIVA for mechanical thrombectomy had significantly increased odds of good functional outcome at 90 days and a non-significant trend towards decrease in mortality. These findings warrant further investigation with large randomized, prospective trials.
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Affiliation(s)
- Byrappa Vinay
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, UAE.
| | - Nitin Manohara
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, UAE
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13
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Zhang T, Deng D, Huang S, Fu D, Wang T, Xu F, Ma L, Ding Y, Wang K, Wang Y, Zhao W, Chen X. A retrospect and outlook on the neuroprotective effects of anesthetics in the era of endovascular therapy. Front Neurosci 2023; 17:1140275. [PMID: 37056305 PMCID: PMC10086253 DOI: 10.3389/fnins.2023.1140275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Studies on the neuroprotective effects of anesthetics were carried out more than half a century ago. Subsequently, many cell and animal experiments attempted to verify the findings. However, in clinical trials, the neuroprotective effects of anesthetics were not observed. These contradictory results suggest a mismatch between basic research and clinical trials. The Stroke Therapy Academic Industry Roundtable X (STAIR) proposed that the emergence of endovascular thrombectomy (EVT) would provide a proper platform to verify the neuroprotective effects of anesthetics because the haemodynamics of patients undergoing EVT is very close to the ischaemia–reperfusion model in basic research. With the widespread use of EVT, it is necessary for us to re-examine the neuroprotective effects of anesthetics to guide the use of anesthetics during EVT because the choice of anesthesia is still based on team experience without definite guidelines. In this paper, we describe the research status of anesthesia in EVT and summarize the neuroprotective mechanisms of some anesthetics. Then, we focus on the contradictory results between clinical trials and basic research and discuss the causes. Finally, we provide an outlook on the neuroprotective effects of anesthetics in the era of endovascular therapy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Xiangdong Chen
- *Correspondence: Xiangdong Chen, ; orcid.org/0000-0003-3347-2947
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14
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Campbell D, Butler E, Barber PA. End the confusion: general anaesthesia improves patient outcomes in endovascular thrombectomy. Br J Anaesth 2022; 129:461-464. [PMID: 35868883 DOI: 10.1016/j.bja.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/23/2022] [Accepted: 06/17/2022] [Indexed: 11/22/2022] Open
Abstract
Expert physiological and pharmacological care by anaesthetists is required in all stroke endovascular thrombectomy cases. RCTs show clinical benefits in recanalisation rates and functional recovery after endovascular thrombectomy with general anaesthesia compared with sedation. Many stroke centres will require wholesale reorganisation of stroke pathways to ensure anaesthesia services are available for all cases. Anaesthetists have an integral role in improving clinical outcomes in large vessel occlusion stroke.
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Affiliation(s)
| | | | - P Alan Barber
- Auckland City Hospital, Auckland, New Zealand; University of Auckland, Auckland, New Zealand
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15
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Lee CW, Chang YP, Huang YT, Hsing CH, Pang YL, Chuang MH, Wu SZ, Sun CK, Hung KC. General anesthesia but not conscious sedation improves functional outcome in patients receiving endovascular thrombectomy for acute ischemic stroke: A meta-analysis of randomized clinical trials and trial sequence analysis. Front Neurol 2022; 13:1017098. [PMID: 36188372 PMCID: PMC9515609 DOI: 10.3389/fneur.2022.1017098] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/26/2022] [Indexed: 11/22/2022] Open
Abstract
Background This study aimed at comparing the difference in prognostic outcomes between patients receiving general anesthesia (GA) and conscious sedation (CS) for endovascular thrombectomy after acute ischemic stroke. Methods Databases from Medline, Embase, Google scholar, and Cochrane library were searched for randomized controlled studies (RCTs) comparing patients undergoing GA and CS for endovascular thrombectomy following anterior circulation ischemic stroke. The primary outcome was frequency of 90-day good functional outcome [defined as modified Rankin Scale score of ≤ 2], while secondary outcomes included successful recanalization rate (SRR) [i.e., modified thrombolysis in cerebral infarction = 2b or 3], mortality risk, symptomatic intracranial hemorrhage (ICH), procedure-related complications, hypotension, pneumonia, neurological outcome at post-procedure 24–48 h, and puncture-to-recanalization time. Results Six RCTs including 883 patients published between 2016 and 2022 were included. Merged results revealed a higher SRR [risk ratio (RR) = 1.11, 95% CI: 1.03–1.2, p = 0.007; I2 = 29%] and favorable neurological outcomes at 3-months (RR = 1.2, 95% CI: 1.01–1.41, p = 0.04; I2 = 8%) in the GA group compared to CS group, without difference in the risk of mortality (RR = 0.88), symptomatic ICH (RR = 0.91), procedure-related complications (RR = 1.05), and pneumonia (RR = 1.9) as well as post-procedure neurological outcome (MD = −0.21) and successful recanalization time (MD = 3.33 min). However, GA was associated with a higher risk of hypotension compared with that of CS. Conclusion Patients with acute anterior circulation ischemic stroke receiving GA were associated with a higher successful recanalization rate as well as a better 3-month neurological outcome compared to the use of CS. Further investigations are warranted to verify our findings. Systematic review registration www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022342483, identifier: CRD42022342483.
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Affiliation(s)
- Chia-Wei Lee
- Department of Neurology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yang-Pei Chang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan City, Taiwan
| | - Chung-Hsi Hsing
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- Department of Medical Research, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yu-Li Pang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Min-Hsiang Chuang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan City, Taiwan
| | - Su-Zhen Wu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung City, Taiwan
- College of Medicine, I-Shou University, Kaohsiung City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- *Correspondence: Kuo-Chuan Hung
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16
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Shao E, Hasanaly N, Venkatraghavan L. Year in Review: Synopsis of Selected Articles in Neuroanesthesia and Neurocritical Care from 2021. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1744045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThis review is a synopsis of selected articles from neuroscience, neuroanesthesia, and neurocritical care from 2021 (January–December 2021). The journals reviewed include anesthesia journals, critical care medicine journals, neurology, and neurosurgical journals as well as high-impact medical journals such as the Lancet, Journal of American Medical Association, New England Journal of Medicine, and Stroke. This summary of important articles will serve to update the knowledge of anesthesiologists and other perioperative physicians who provide care to neurosurgical and neurocritical care patients. In addition, some of the important narrative reviews that are of interest to neuroanesthesiologists are also listed.
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Affiliation(s)
- Evan Shao
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nahemah Hasanaly
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Lashmi Venkatraghavan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
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17
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Zhao J, Zhu W, Qi Y, Xu G, Liu L, Liu J. Effect of supraglottic airway devices versus endotracheal intubation general anesthesia on outcomes in patients undergoing mechanical thrombectomy: A prospective randomized clinical trial. Medicine (Baltimore) 2022; 101:e29074. [PMID: 35550459 PMCID: PMC9276097 DOI: 10.1097/md.0000000000029074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/24/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND There are still controversies about the optimal anesthesia protocol for patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). The aim of this study was to explore the effect of supraglottic airway device (SAD) versus endotracheal intubation (EI) general anesthesia on clinical and angiographic outcomes in patients with AIS undergoing MT. METHODS One hundred sixteen patients with large-vessel occlusion stroke were randomized to receive either SAD or EI general anesthesia. The primary outcome was the rate of occurrence of >20% fall in mean arterial pressure (MAP). Secondary outcomes included hemodynamics, successful recanalization, time metrics, satisfaction score of neurointerventionalist, number of passes performed, the conversion rate from SAD to EI, the National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT Score before and 24 hours after surgery, length of stay in the stroke unit and hospital, complications and functional independence at discharge, and 90 days after stroke. RESULTS Both the lowest systolic blood pressure and lowest diastolic blood pressure were significantly lower in the EI group (P = .001). The consumption of vasoactive agents, the occurrence of >20% reduction in MAP and time spent with >20% fall in MAP were significantly higher in the EI group (P < .05). Compared with the EI group, the time for door-to-puncture was significantly shorter in the SAD group (P = .015). There were no significant differences with respect to puncture-to-reperfusion time, number of passes performed, rates of successful recanalization, National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT Score 24 hours after surgery. The satisfaction score of neurointerventionalist was significantly lower in the EI group (P = .043). Conversion rate from SAD to EI was 7.41%. There were no significant differences with respect to complications, mortality, and mean Modified Rankin Scale scores both at discharge and 90-day after stroke. However, length of stroke unit and hospital stays were significantly shorter in the SAD group (P < .05). CONCLUSION AIS patients undergoing MT with SAD general anesthesia led to more stable hemodynamics, higher satisfaction score of neurointerventionalist, shorter door-to-puncture time, length of stroke unit, and hospital stay. However, there were no significant differences between the 2 groups on the angiographic and functional outcomes both at discharge and 90 days after stroke.
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18
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Simonsen CZ, Bösel J, Rasmussen M. Periprocedural Management During Stroke Thrombectomy. Neurology 2021; 97:S105-S114. [PMID: 34785609 DOI: 10.1212/wnl.0000000000012798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 02/24/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF REVIEW Endovascular therapy (EVT) for acute ischemic stroke caused by large vessel occlusion is a powerful and evidence-based tool to achieve reperfusion and results in improved neurologic outcome. Focus has now shifted toward optimizing the procedure. We reviewed the relevant current literature on periprocedural stroke care such as pretreatment with IV tissue plasminogen activator (tPA), choice of anesthesia, ventilation strategy, and blood pressure management. RECENT FINDINGS IV tPA should not be withheld in a patients with stroke eligible for EVT. A meta-analysis of randomized trials on general anesthesia (GA) vs procedural sedation has shown better neurologic outcomes with protocol-based GA in centers with dedicated neuroanesthesia teams. There are no data from randomized trials on blood pressure control, but according to available evidence, systolic blood pressure should probably be held at >140 mm Hg during the procedure and <160 mm Hg after reperfusion. In ventilated patients, extreme deviations from normoxemia and normocapnia should be avoided. SUMMARY Periprocedural care influences the outcome after EVT for large vessel ischemic stroke. More evidence from prospective ongoing and future studies is urgently needed to identify its optimization.
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Affiliation(s)
- Claus Z Simonsen
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany.
| | - Julian Bösel
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany
| | - Mads Rasmussen
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany
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19
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Simonsen CZ, Rasmussen M, Schönenberger S, Hendén PL, Bösel J, Valentin JB. General anesthesia during endovascular therapy for acute ischemic stroke: benefits beyond better reperfusion? J Neurointerv Surg 2021; 14:767-771. [PMID: 34475256 DOI: 10.1136/neurintsurg-2021-017999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/19/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Endovascular therapy (EVT) is standard of care for stroke caused by large vessel occlusion. Whether EVT should be performed under general anesthesia (GA) or conscious sedation (CS) is controversial. While a meta-analysis of randomized trials showed better outcome for EVT under GA, observational studies suggested the opposite. A proposed advantage of GA is better reperfusion achieved via more successful handling of the immobile patient. The aim of this study was to investigate if the good outcome seen in patients treated under GA was mediated by better reperfusion. METHODS The meta-analysis included 368 individual patients from three randomized controlled trials, of whom 185 patients were randomized to CS. A mediator analysis was performed to examine if the better outcome in the GA arm was driven by higher reperfusion rate. RESULTS The total effect showed a risk difference (RD) of 0.15 (95% CI 0.04 to 0.25), associating GA with a beneficial outcome. The direct effect of GA constituted a large portion, with an RD of 0.12 (95% CI 0.01 to 0.22), while only a small portion was mediated through the degree of reperfusion, with an RD of 0.03 (95% CI 0.02 to 0.04). CONCLUSION The better outcome after EVT in the GA arm was mainly a direct effect-that is, an effect that was not explained by better reperfusion. We also found a better outcome in the GA arm when reperfusion was not achieved. Whether this is an effect of the stable condition and blood pressure under GA or a neuroprotective effect will need to be investigated in future research.
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Affiliation(s)
- Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark .,Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mads Rasmussen
- Department of Anesthesia, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | | | - Pia Löwhagen Hendén
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, General Hospital Kassel, Kassel, Germany
| | - Jan Brink Valentin
- Danish Centre for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
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Abstract
Perioperative stroke is defined as an ischemic cerebrovascular event that occurs during or within 30 days after surgery and is associated with an increased perioperative risk of morbidity and mortality. Depending on the type of surgery stroke is diagnosed in up to 11% of all patients in the perioperative period. Patients with a history of ischemic stroke or transitory ischemic attack have an increased risk for perioperative stroke. Therefore, a critical assessment of indications and the timing of surgery are crucial to prevent recurring stroke in this patient population. Importantly, individualized blood pressure management is essential for optimization of cerebral perfusion during the perioperative period.This article provides a summary of the epidemiology, risk factors, and etiology of perioperative stroke. Moreover, possible preventive strategies relevant for the anesthesiologist are reviewed.
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Affiliation(s)
- M Fischer
- Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - U Kahl
- Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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21
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Deng C, Campbell D, Diprose W, Eom C, Wang K, Robertson N, Short TG, Brew S, Caldwell J, McGuinness B, Barber PA. A pilot randomised controlled trial of the management of systolic blood pressure during endovascular thrombectomy for acute ischaemic stroke. Anaesthesia 2019; 75:739-746. [DOI: 10.1111/anae.14940] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 01/03/2023]
Affiliation(s)
- C. Deng
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - D. Campbell
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - W. Diprose
- Department of Radiology Auckland City Hospital Auckland New Zealand
| | - C. Eom
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - K. Wang
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - N. Robertson
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - T. G. Short
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - S. Brew
- Department of Radiology Auckland City Hospital Auckland New Zealand
| | - J. Caldwell
- Department of Radiology Auckland City Hospital Auckland New Zealand
| | - B. McGuinness
- Department of Radiology Auckland City Hospital Auckland New Zealand
| | - P. A. Barber
- Department of Medicine University of Auckland Auckland New Zealand
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