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Gaspari A, Vaccari G, Arturi F, Melegari G, Baroni S. Anesthesia for Endovascular Therapy for Stroke. Neurol Int 2024; 16:663-672. [PMID: 38921954 PMCID: PMC11206672 DOI: 10.3390/neurolint16030050] [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: 03/01/2024] [Revised: 06/01/2024] [Accepted: 06/13/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND In patients with acute ischemic stroke, the standard of care is to perform intra-arterial endovascular thrombectomy in addition to intravenous thrombolysis. In this study, we investigated the different anesthetic techniques chosen for this procedure and clinical outcomes. METHODS Patients undergoing endovascular procedures were divided into three groups. The first group consisted of patients who received general anesthesia, the second group underwent the procedure under conscious sedation and local anesthesia at the catheter insertion site, and lastly the third group included patients who received only local anesthesia at the catheter insertion site, without sedation. RESULTS During the endovascular procedure, we did not notice significant differences in vital parameters, in particular the mean blood pressure (MAP) between patients treated with different types of anesthesia. Also, the duration of the revascularization did not show significant differences between the three groups. The main point is the absence of differences in terms of functional and clinical outcomes, using various scores as reference, such as the National Institutes of Health Stroke Scale (NIHSS) score at 7 days, NIHSS and Modified Rankin Scale (MRS) at time of discharge, and MRS after 3 months. These scores did not show significant differences in groups treated with different types of anesthesia. CONCLUSIONS The rate of success of the revascularization procedure is almost overlapping between patients treated with conscious sedation and general anesthesia. In addition, we did not notice significant differences between groups in terms of functional and clinical outcomes. Considering the possible usefulness of applying conscious sedation, at OCSAE of Baggiovara, an internal protocol for conscious sedation was introduced to standardize the treatment in patients undergoing endovascular procedures.
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Affiliation(s)
- Arianna Gaspari
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria di Modena, Via del Pozzo 71, 41125 Modena, Italy; (A.G.); (S.B.)
| | - Giulia Vaccari
- School of Anesthesia and Intensive Care, University of Modena and Reggio Emilia, Via del Pozzo 71, 41125 Modena, Italy; (G.V.); (F.A.)
| | - Federica Arturi
- School of Anesthesia and Intensive Care, University of Modena and Reggio Emilia, Via del Pozzo 71, 41125 Modena, Italy; (G.V.); (F.A.)
| | - Gabriele Melegari
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria di Modena, Via del Pozzo 71, 41125 Modena, Italy; (A.G.); (S.B.)
| | - Stefano Baroni
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria di Modena, Via del Pozzo 71, 41125 Modena, Italy; (A.G.); (S.B.)
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Medicherla C, Pashun R, Al-Mufti F. Review of Cerebral Collateral Circulation and Insight into Cardiovascular Strategies to Limit Collateral Damage in Ischemic Stroke. Cardiol Rev 2024; 32:188-193. [PMID: 37729598 DOI: 10.1097/crd.0000000000000614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Cerebral collateral circulation is a dynamic and adaptive process by which alternative vascular pathways supply perfusion to ischemic brain tissue in the event of an arterial occlusion. This complicated network of blood vessels that acts as a natural bypass plays a pivotal role in stroke pathophysiology and has become a key area of study given its significance in stroke treatment and patient outcomes. In this review, we will study the factors influencing the formation, recruitment, and endurance of collateral vessels; discuss imaging modalities for quantitative and qualitative assessment of this network; explore the role of collaterals in stroke management; and highlight several cardiovascular strategies to minimize damage to collaterals and optimize stroke outcomes.
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Affiliation(s)
| | - Raymond Pashun
- Department of Cardiology, New York University Langone Health, New York, NY
| | - Fawaz Al-Mufti
- Department of Neurology, Neurosurgery, and Radiology, New York Medical College, Valhalla, NY
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Viderman D, Bilotta F, Badenes R, Abdildin Y. Anesthetic management of endovascular neurosurgical procedures in acute ischemic stroke patients: A systematic review of meta-analyses. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:580-592. [PMID: 37678462 DOI: 10.1016/j.redare.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 02/06/2023] [Indexed: 09/09/2023]
Abstract
Restoration of cerebral circulation in the ischemic area is the most critical treatment task for reducing irreversible neuronal injury in ischemic stroke patients. The recanalización of appropriately selected patients became indispensable for improving clinical outcomes and resulted in the widespread revascularization techniques. There is no clear answer as to which anesthetic modality to use in ischemic stroke patients undergoing neuro-endovascular procedures. The purpose of this systematic review is to conduct a qualitative analysis of systematic reviews and meta-analyses (RSs & MAs) comparing general anesthesia and non-general anesthesia methods for cerebral endovascular interventions in acute ischemic stroke patients. We developed a protocol with the inclusion and exclusion criteria for matched publications and conducted a literature search in PubMed and Google Scholar. The literature search yielded 52 potential publications. Ten relevant RSs & MAs were included and analysed in this review. The decision about which anesthesia method to use for endovascular procedures in managing acute ischemic stroke patients should be made based on the patient's personal characteristics, pathophysiological phenotypes, clinical characteristics, and institutional experience.
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Affiliation(s)
- D Viderman
- Department of Surgery (Section of Anesthesiology, Intensive Care, and Pain Medicine), Nazarbayev University School of Medicine (NUSOM), Astana, Kazakhstan.
| | - F Bilotta
- Departamento de Anestesia y Cuidado Intensivo, Universidad de Roma La Sapienza, Roma, Italy
| | - R Badenes
- Departamento de Anestesiología y Cuidado Intensivo, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
| | - Y Abdildin
- School of Engineering and Digital Sciences, Nazarbayev University, Astana, Kazakhstan
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Lu Y, Xu P, Wang J, Xiao L, Zhang P, Duan Z, Liu D, Liu C, Wang D, Wang D, Zhang C, Yao T, Sun W, Cheng Z, Li M. General anesthesia vs. non-general anesthesia for vertebrobasilar stroke endovascular therapy. Front Neurol 2023; 14:1104487. [PMID: 36816562 PMCID: PMC9932259 DOI: 10.3389/fneur.2023.1104487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
Background The optimal type of anesthesia for acute vertebrobasilar artery occlusion (VBAO) remains controversial. We aimed to assess the influence of anesthetic management on the outcomes in VBAO patients received endovascular treatment (EVT). Methods Patients underwent EVT for acute VBAO at 21 stroke centers in China were retrospectively enrolled and compared between the general anesthesia (GA) group and non-GA group. The primary outcome was the favorable outcome, defined as a modified Rankin Scale (mRS) score 0-3 at 90 days. Secondary outcomes included functional independence (90-day mRS score 0-2), and the rate of successful reperfusion. The safety outcomes included all-cause mortality at 90 days, the occurrence of any procedural complication, and the rate of symptomatic intracranial hemorrhage (sICH). In addition, we performed analyses of the outcomes in subgroups that were defined by Glasgow Coma Scale (GCS) score (≤8 or >8). Results In the propensity score matched cohort, there were no difference in the primary outcome, secondary outcomes and safety outcomes between the two groups. Among patients with a GCS score of 8 or less, the proportion of successful reperfusion was significantly higher in the GA group than the non-GA group (aOR, 3.57, 95% CI 1.06-12.50, p = 0.04). In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar results were found. Conclusions Patients placed under GA during EVT for VBAO appear to be as effective and safe as non-GA. Furthermore, GA might yield better successful reperfusion for worse presenting GCS score (≤8). Registration URL: http://www.chictr.org.cn/; Unique identifier: ChiCTR2000033211.
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Affiliation(s)
- Yanan Lu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Pengfei Xu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Jinjing Wang
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Lulu Xiao
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Pan Zhang
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Zuowei Duan
- Department of Neurology, Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Dezhi Liu
- Department of Neurology, Shuguang Hospital Affiliated With Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chaolai Liu
- Department of Neurology, The First People's Hospital of Jining, Jining, Shandong, China
| | - Delong Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Di Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Chao Zhang
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Tao Yao
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Wen Sun
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Zhaozhao Cheng
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China,*Correspondence: Zhaozhao Cheng ✉
| | - Min Li
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China,Min Li ✉
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Krebs S, Ferrari J, Schürer A, Chiari A, Neumann C, Lang W, Sykora M. Pre-hospital and intrahospital workflow optimization for patients with suspected ischemic stroke due to large vessel occlusion - findings from a tertiary care facility. BMC Neurol 2022; 22:497. [PMID: 36550453 PMCID: PMC9773532 DOI: 10.1186/s12883-022-03033-1] [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: 10/14/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The efficacy of recanalization treatment in patients with ischemic stroke due to large vessel occlusion (LVO) is highly time dependent. We aimed to investigate the effects of an optimization of prehospital and intrahospital pathways on time metrics and efficacy of endovascular treatment in ischemic stroke due to LVO. METHODS Patients treated with mechanical thrombectomy (MT) at the Hospital of St. John of God Vienna, Austria, between 2013 and 2020 were extracted from the Austrian Stroke Unit Registry. Study endpoints including time metrics, early neurological improvement and functional outcome measured by modified Rankin Scale (mRS) at 3 months were compared before and after optimization of prehospital and intrahospital pathways. RESULTS Two hundred ninety-nine patients were treated with MT during the study period, 94 before and 205 after the workflow optimization. Workflow optimization was significantly associated with time metrics improvement (door to groin puncture time 45 versus 31 min; p < 0.001), rates of neurological improvement (NIHSS ≥ 8: 30 (35%) vs. 70 (47%), p = 0.04) and radiological outcome (TICI ≥ 2b: 71 (75%) versus 153 (87%); p = 0.013). Functional outcome (mRS 0-2: 17 (18%) versus 57 (28%); p = 0.067) and mortality (34 (37%) versus 54 (32%); p = 0.450) at 3 months showed a non-significant trend in the later time period group. CONCLUSION The implementation of workflow optimization was associated a significant reduction of intrahospital time delays and improvement of neurological and radiological outcomes.
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Affiliation(s)
- Stefan Krebs
- Department of Neurology, St. John’s Hospital, Johannes Von Gott Platz 1, 1020 Vienna, Austria
| | - Julia Ferrari
- Department of Neurology, St. John’s Hospital, Johannes Von Gott Platz 1, 1020 Vienna, Austria
| | - Alice Schürer
- grid.263618.80000 0004 0367 8888Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Astrid Chiari
- Department of Anesthesiology, St. John’s Hospital, Vienna, Austria
| | | | - Wilfried Lang
- Department of Neurology, St. John’s Hospital, Johannes Von Gott Platz 1, 1020 Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Marek Sykora
- Department of Neurology, St. John’s Hospital, Johannes Von Gott Platz 1, 1020 Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty, Sigmund Freud University, Vienna, Austria
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Parr MS, Salehani A, Ogilvie M, Ethan Tabibian B, Rahm S, Hale AT, Tsemo GB, Aluri A, Kim J, Mathru M, Jones JGA. The effect of procedural end-tidal CO2 on infarct expansion during anterior circulation thrombectomy. Interv Neuroradiol 2022:15910199221143175. [PMID: 36464668 DOI: 10.1177/15910199221143175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Carbon dioxide is a potent cerebral vasodilator that may influence outcomes after ischemic stroke. The objective of this study was to investigate the effect of intraprocedural mean end-tidal CO2 (ETCO2) levels on core infarct expansion and neurologic outcome following thrombectomy for anterior circulation ischemic stroke. METHODS A retrospective review was conducted of consecutive patients from March 2020 to June 2021 who underwent mechanical thrombectomy for acute anterior circulation ischemic stroke under general anesthesia and achieved successful recanalization (Thrombolysis in Cerebral Infarction [TICI] ≥ 2b). Only patients with CT perfusion, procedural ETCO2, and postoperative MRI data were included. Segmentation software was used for multi-parametric image analysis. Normocarbia defined as mean ETCO2 of 35 mmHg was used to dichotomize subjects. Univariate and multivariate statistics were applied. RESULTS Fifty-eight patients met criteria for analysis. Of these, 44 had TICI 3 recanalization, 9 had TICI 2c, and 5 had TICI 2b. Within this combined recanalization group, patients with mean ETCO2 > 35 had significantly higher rates of functional independence at 90 days. Although patients tended to salvage more penumbra and experience smaller final infarcts when ETCO2 exceeded 35 mmHg, this did not reach statistical significance. CONCLUSIONS Stroke patients who underwent successful thrombectomy with general anesthesia achieved higher rates of functional independence when procedural ETCO2 exceeded 35 mmHg. Further studies to confirm this effect and investigate optimal ETCO2 parameters should be considered.
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Affiliation(s)
- Matthew S Parr
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Arsalaan Salehani
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark Ogilvie
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Radiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - B Ethan Tabibian
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sage Rahm
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew T Hale
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Georges Bouobda Tsemo
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Akshay Aluri
- Heersink School of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jinsuh Kim
- Department of Radiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mali Mathru
- Department of Anesthesiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jesse G A Jones
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Radiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
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Tosello R, Riera R, Tosello G, Clezar CN, Amorim JE, Vasconcelos V, Joao BB, Flumignan RL. Type of anaesthesia for acute ischaemic stroke endovascular treatment. Cochrane Database Syst Rev 2022; 7:CD013690. [PMID: 35857365 PMCID: PMC9298671 DOI: 10.1002/14651858.cd013690.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of mechanical thrombectomy to restore intracranial blood flow after proximal large artery occlusion by a thrombus has increased over time and led to better outcomes than intravenous thrombolytic therapy alone. Currently, the type of anaesthetic technique during mechanical thrombectomy is under debate as having a relevant impact on neurological outcomes. OBJECTIVES To assess the effects of different types of anaesthesia for endovascular interventions in people with acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Specialised Register of Trials on 5 July 2022, and CENTRAL, MEDLINE, and seven other databases on 21 March 2022. We performed searches of reference lists of included trials, grey literature sources, and other systematic reviews. SELECTION CRITERIA: We included all randomised controlled trials with a parallel design that compared general anaesthesia versus local anaesthesia, conscious sedation anaesthesia, or monitored care anaesthesia for mechanical thrombectomy in acute ischaemic stroke. We also included studies reported as full-text, those published as abstract only, and unpublished data. We excluded quasi-randomised trials, studies without a comparator group, and studies with a retrospective design. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria, extracted data, and assessed the risk of bias and the certainty of the evidence using the GRADE approach. The outcomes were assessed at different time periods, ranging from the onset of the stroke symptoms to 90 days after the start of the intervention. The main outcomes were functional outcome, neurological impairment, stroke-related mortality, all intracranial haemorrhage, target artery revascularisation status, time to revascularisation, adverse events, and quality of life. All included studies reported data for early (up to 30 days) and long-term (above 30 days) time points. MAIN RESULTS We included seven trials with 982 participants, which investigated the type of anaesthesia for endovascular treatment in large vessel occlusion in the intracranial circulation. The outcomes were assessed at different time periods, ranging from the onset of stroke symptoms to 90 days after the procedure. Therefore, all included studies reported data for early (up to 30 days) and long-term (above 30 up to 90 days) time points. General anaesthesia versus non-general anaesthesia(early) We are uncertain about the effect of general anaesthesia on functional outcomes compared to non-general anaesthesia (mean difference (MD) 0, 95% confidence interval (CI) -0.31 to 0.31; P = 1.0; 1 study, 90 participants; very low-certainty evidence) and in time to revascularisation from groin puncture until the arterial reperfusion (MD 2.91 minutes, 95% CI -5.11 to 10.92; P = 0.48; I² = 48%; 5 studies, 498 participants; very low-certainty evidence). General anaesthesia may lead to no difference in neurological impairment up to 48 hours after the procedure (MD -0.29, 95% CI -1.18 to 0.59; P = 0.52; I² = 0%; 7 studies, 982 participants; low-certainty evidence), and in stroke-related mortality (risk ratio (RR) 0.98, 95% CI 0.52 to 1.84; P = 0.94; I² = 0%; 3 studies, 330 participants; low-certainty evidence), all intracranial haemorrhages (RR 0.92, 95% CI 0.65 to 1.29; P = 0.63; I² = 0%; 5 studies, 693 participants; low-certainty evidence) compared to non-general anaesthesia. General anaesthesia may improve adverse events (haemodynamic instability) compared to non-general anaesthesia (RR 0.21, 95% CI 0.05 to 0.79; P = 0.02; I² = 71%; 2 studies, 229 participants; low-certainty evidence). General anaesthesia improves target artery revascularisation compared to non-general anaesthesia (RR 1.10, 95% CI 1.02 to 1.18; P = 0.02; I² = 29%; 7 studies, 982 participants; moderate-certainty evidence). There were no available data for quality of life. General anaesthesia versus non-general anaesthesia (long-term) There is no difference in general anaesthesia compared to non-general anaesthesia for dichotomous and continuous functional outcomes (dichotomous: RR 1.21, 95% CI 0.93 to 1.58; P = 0.16; I² = 29%; 4 studies, 625 participants; low-certainty evidence; continuous: MD -0.14, 95% CI -0.34 to 0.06; P = 0.17; I² = 0%; 7 studies, 978 participants; low-certainty evidence). General anaesthesia showed no changes in stroke-related mortality compared to non-general anaesthesia (RR 0.88, 95% CI 0.64 to 1.22; P = 0.44; I² = 12%; 6 studies, 843 participants; low-certainty evidence). There were no available data for neurological impairment, all intracranial haemorrhages, target artery revascularisation status, time to revascularisation from groin puncture until the arterial reperfusion, adverse events (haemodynamic instability), or quality of life. Ongoing studies We identified eight ongoing studies. Five studies compared general anaesthesia versus conscious sedation anaesthesia, one study compared general anaesthesia versus conscious sedation anaesthesia plus local anaesthesia, and two studies compared general anaesthesia versus local anaesthesia. Of these studies, seven plan to report data on functional outcomes using the modified Rankin Scale, five studies on neurological impairment, six studies on stroke-related mortality, two studies on all intracranial haemorrhage, five studies on target artery revascularisation status, four studies on time to revascularisation, and four studies on adverse events. One ongoing study plans to report data on quality of life. One study did not plan to report any outcome of interest for this review. AUTHORS' CONCLUSIONS In early outcomes, general anaesthesia improves target artery revascularisation compared to non-general anaesthesia with moderate-certainty evidence. General anaesthesia may improve adverse events (haemodynamic instability) compared to non-general anaesthesia with low-certainty evidence. We found no evidence of a difference in neurological impairment, stroke-related mortality, all intracranial haemorrhage and haemodynamic instability adverse events between groups with low-certainty evidence. We are uncertain whether general anaesthesia improves functional outcomes and time to revascularisation because the certainty of the evidence is very low. However, regarding long-term outcomes, general anaesthesia makes no difference to functional outcomes compared to non-general anaesthesia with low-certainty evidence. General anaesthesia did not change stroke-related mortality when compared to non-general anaesthesia with low-certainty evidence. There were no reported data for other outcomes. In view of the limited evidence of effect, more randomised controlled trials with a large number of participants and good protocol design with a low risk of bias should be performed to reduce our uncertainty and to aid decision-making in the choice of anaesthesia.
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Affiliation(s)
- Renato Tosello
- Department of Neurointerventional Radiology, Hospital Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
| | - Rachel Riera
- Centre of Health Technology Assessment, Universidade Federal de São Paulo, São Paulo, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde (NEP-Sbeats), Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Caroline Nb Clezar
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jorge E Amorim
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Benedito B Joao
- Division of Anesthesia, Pain, and Intensive Medicine, Department of Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Alsrouji OK, Chebl AB. Acute Neurointervention for Ischemic Stroke. Interv Cardiol Clin 2022; 11:339-347. [PMID: 35710287 DOI: 10.1016/j.iccl.2022.03.006] [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] [Indexed: 06/15/2023]
Abstract
Acute ischemic stroke (AIS) is one of the major causes of death worldwide and a leading cause of disability. Until recently treatment of AIS was supportive, and in a minority of patients intravenous thrombolysis was available but with marginal clinical benefit. With the advent of stent retrievers, distal aspiration catheters as well as improved patient selection neurologic outcomes have greatly improved. However, the care of patients with AIS is still challenging and requires the early recognition of stroke symptoms, extensive diagnostic testing, early intervention, and advanced nursing and critical care.
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Affiliation(s)
- Owais Khadem Alsrouji
- Department of Neurosurgery, Henry Ford Hospital, K11, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Alex Bou Chebl
- Division of Vascular Neurology, Department of Neurology, Harris Comprehensive Stroke Center, Henry Ford Health System, Clara Ford Pavillion, Room 453, 2799 W Grand Boulevard, Detroit, MI 48202, USA.
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Patient Pathways During Acute in-Hospital Stroke Treatment: A Qualitative Multi-Method Study. Int J Integr Care 2022; 22:16. [PMID: 35291205 PMCID: PMC8877851 DOI: 10.5334/ijic.5657] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/28/2022] [Indexed: 11/20/2022] Open
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Ma G, Sun X, Cheng H, Burgin WS, Luo W, Jia W, Liu Y, He W, Geng X, Zhu L, Chen X, Shi H, Xu H, Zhang L, Wang A, Mo D, Ma N, Gao F, Song L, Huo X, Deng Y, Liu L, Luo G, Jia B, Tong X, Liu L, Ren Z, Miao Z. Combined Approach to Eptifibatide and Thrombectomy in Acute Ischemic Stroke Because of Large Vessel Occlusion: A Matched-Control Analysis. Stroke 2022; 53:1580-1588. [PMID: 35105182 DOI: 10.1161/strokeaha.121.036754] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients undergoing mechanical thrombectomy (MT), adjunctive antithrombotic might improve angiographic reperfusion, reduce the risk of distal emboli and reocclusion but possibly expose patients to a higher intracranial hemorrhage risk. This study evaluated the safety and efficacy of combined MT plus eptifibatide for acute ischemic stroke. METHODS This was a propensity-matched analysis of data from 2 prospective trials in Chinese populations: the ANGEL-ACT trial (Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke) in 111 hospitals between November 2017 and March 2019, and the EPOCH trial (Eptifibatide in Endovascular Treatment of Acute Ischemic Stroke) in 15 hospitals between April 2019 and March 2020. The primary efficacy outcome was good outcome (modified Rankin Scale score 0-2) at 3 months. Secondary efficacy outcomes included the distribution of 3-month modified Rankin Scale scores and poor outcome (modified Rankin Scale score 5-6) and successful recanalization. The safety outcomes included any intracranial hemorrhage, symptomatic intracranial hemorrhage, and 3-month mortality. Mixed-effects logistic regression models were used to account for within-hospital clustering in adjusted analyses. RESULTS Eighty-one combination arm EPOCH subjects were matched with 81 ANGEL-ACT noneptifibatide patients. Compared with the no eptifibatide group, the eptifibatide group had significantly higher rates of successful recanalization (91.3% versus 81.5%; P=0.043) and 3-month good outcomes (53.1% versus 33.3%; P=0.016). No significant difference was found in the remaining outcome measures between the 2 groups. All outcome measures of propensity score matching were consistent with mixed-effects logistic regression models in the total population. CONCLUSIONS This matched-control study demonstrated that MT combined with eptifibatide did not raise major safety concerns and showed a trend of better efficacy outcomes compared with MT alone. Overall, eptifibatide shows potential as a periprocedural adjunctive antithrombotic therapy when combined with MT. Further randomized controlled trials of MT plus eptifibatide should be prioritized. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03844594 (EPOCH), NCT03370939 (ANGEL-ACT).
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Affiliation(s)
- Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Huiran Cheng
- Department of Neurosurgery, Anyang People's Hospital, China (H.C., L.Z.)
| | - W Scott Burgin
- Department of Neurology, Morsani College of Medicine University of South Florida, Tampa (W.S.B.)
| | - Weiliang Luo
- Department of Neurology, Huizhou Municipal Central Hospital, China (W.L.)
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Teaching Hospital, Capital Medical University, China (W.J.)
| | - Yajie Liu
- Department of Neurology, Shenzhen Hospital, Southern Medical University, China (Y.L.)
| | - Wenlong He
- Department of Neurology, Xinxiang Central Hospital, China (W.H.)
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, China (X.G.)
| | - Liangfu Zhu
- Department of Neurosurgery, Anyang People's Hospital, China (H.C., L.Z.).,Department of Cerebral Vascular Diseases, Interventional Center, Henan Provincial People's Hospital, Zhengzhou, China (L.Z.)
| | - Xingyu Chen
- Department of Neurology, Zhongshan Hospital Xiamen University, China (X.C.)
| | - Huaizhang Shi
- Department of Neurosurgery, the First Affiliated Hospital of Harbin Medical University, China (H.S.)
| | - Haowen Xu
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, China (H.X,)
| | | | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University (A.W.)
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Ligang Song
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Yiming Deng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Lian Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.).,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (L.L.)
| | - Gang Luo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | | | | | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa (Z.R.)
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
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11
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Yeo LLL, Jing M, Bhogal P, Tu T, Gopinathan A, Yang C, Tan BYQ, Arnberg F, Sia CH, Holmin S, Andersson T. Evidence-Based Updates to Thrombectomy: Targets, New Techniques, and Devices. Front Neurol 2021; 12:712527. [PMID: 34566856 PMCID: PMC8459011 DOI: 10.3389/fneur.2021.712527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/30/2021] [Indexed: 01/23/2023] Open
Abstract
Endovascular thrombectomy (EVT) has been validated in several randomized controlled trials in recent years for its efficacy in the treatment of acute ischemic strokes (AIS) and is now the standard of care according to international guidelines. However, in about 20% of EVT procedures, recanalization is not achieved, and over 50% of patients who undergo EVT still do not have good functional outcome. In this article, we provide an extensive review of the latest evidence and developments in the field of EVT, with particular focus on the factors that improve patient outcomes. These factors include new and adjunctive techniques such as combination of direct aspiration and stent retriever, intra-arterial urokinase or 2b/3a inhibitors, rescue stenting, as well as novel devices including balloon guide catheters and the newer generations of aspiration catheters and stent retrievers. We also examined the latest notion of using first-pass effect (FPE) as the target to achieve during EVT, which has been associated with an improved functional outcome. While the field of EVT has been rapidly evolving, further research is required in specific AIS patient populations such as those with large ischemic core, late presentation beyond 24 h, posterior circulation strokes, and with distal medium vessel occlusion or tandem lesions to better assess its efficacy and safety.
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Affiliation(s)
- Leonard L L Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Mingxue Jing
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Pervinder Bhogal
- Department of Neuroradiology, St. Bartholomew's and the Royal London Hospital, London, United Kingdom
| | - Tianming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Anil Gopinathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Cunli Yang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Benjamin Y Q Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
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12
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Oliveira RSSD, Ciarlariello VB, Martins HNF, Lobato MDS, Miranda RCAN, Freitas FFMD, Massaud RM, Abud TG, Baccin CE, Silva GS. Blood pressure behavior during mechanical thrombectomy and drugs used for conscious sedation or general anesthesia. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:660-665. [PMID: 34550190 DOI: 10.1590/0004-282x-anp-2020-0243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/12/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The optimal blood pressure (BP) during mechanical thrombectomy for acute ischemic stroke is currently unclear. OBJECTIVE To investigate BP behavior during mechanical thrombectomy in patients with acute ischemic stroke and its relationship with drugs used for sedation or general anesthesia. Additionally, we investigated the association between BP oscillation during mechanical thrombectomy and recanalization status, and with functional outcome at discharge. METHODS Consecutive patients treated with mechanical thrombectomy for acute ischemic stroke were evaluated in a tertiary hospital from December/2009 to December/2015. Maximum, minimum, and mean systolic and diastolic BP, and mean arterial pressures were collected during the procedure. Sedative drugs were also reviewed. RESULTS Fifty-three patients with a mean age of 71.9 years (60.4% men) were treated with mechanical thrombectomy. The mean reduction in systolic BP and mean arterial pressure from hospital admission to mechanical thrombectomy were respectively 42 and 36 mmHg. During the procedure, oscillations were 50.4 mmHg for systolic, and 33.2 mmHg for diastolic BP. Patients treated with neuromuscular blocking drugs had more oscillation in systolic BP from hospital admission to procedure (51.1 versus 26.2 mmHg, P=0.06). The use of cisatracurium (43.9 versus 29.6 mmHg, P=0.02) and succinylcholine (44.7 versus 29.3 mmHg, P=0.01) were associated with a significant drop in BP during the procedure. CONCLUSIONS Significant BP oscillation occurs during mechanical thrombectomy. Drugs used for conscious sedation or general anesthesia, specifically neuromuscular blocking agents, might have an influence upon BP levels.
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Affiliation(s)
| | - Vinícius Boaratti Ciarlariello
- Hospital Israelita Albert Einstein, São Paulo SP, Brazil.,Universidade Federal de São Paulo, Disciplina de Neurologia Clínica, São Paulo SP, Brazil
| | | | | | | | | | | | | | | | - Gisele Sampaio Silva
- Hospital Israelita Albert Einstein, São Paulo SP, Brazil.,Universidade Federal de São Paulo, Disciplina de Neurologia Clínica, São Paulo SP, Brazil
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13
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Hamidianjahromi A, Mowla A. Letter regarding 'Neurointervention for emergent large vessel occlusion strokes during the COVID-19 pandemic'. J Neurointerv Surg 2021; 13:e20. [PMID: 33875553 DOI: 10.1136/neurintsurg-2021-017537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Anahid Hamidianjahromi
- Department of Neurology, Jahrom University of Medical Sciences, Jahrom, Iran (the Islamic Republic of)
| | - Ashkan Mowla
- Department of Neurological Surgery, University of Southern California, Los Angeles, California, USA
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14
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Yavagal DR, Saini V, Inoa V, Gardener HE, Martins SO, Fakey M, Ortega S, Mansour O, Leung T, Al-Mufti F, Jadhav AP, Potter-Vig J, Mairal A, Zhongrong M, Sylaja PN, Demchuk AM. International Survey of Mechanical Thrombectomy Stroke Systems of Care During COVID-19 Pandemic. J Stroke Cerebrovasc Dis 2021; 30:105806. [PMID: 34058701 PMCID: PMC8023209 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105806] [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: 12/20/2020] [Revised: 03/20/2021] [Accepted: 03/31/2021] [Indexed: 12/15/2022] Open
Abstract
Background The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on various aspects of thrombectomy systems. Aims We conducted a convenience electronic survey with a 21-item questionnaire aimed to identify the changes in stroke admission volumes and thrombectomy treatment practices seen during a specified time period of the COVID-19 pandemic. Methods The survey was designed using Qualtrics software and sent to stroke and neuro-interventional physicians around the world who are part of the Global Executive Committee (GEC) of Mission Thrombectomy 2020, a global coalition under the aegis of Society of Vascular and Interventional Neurology, between April 5th and May 15th, 2020. Results There were 113 responses to the survey across 25 countries with a response rate of 31% among the GEC members. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during the COVID-19 pandemic period until May 15th, 2020 compared to pre-pandemic months. The intubation policy for MT procedures during the pandemic was highly variable across participating centers: 44% preferred intubating all patients, including 25% of centers that changed their policy to preferred-intubation (PI) from preferred non-intubation (PNI). On the other hand, 56% centers preferred not intubating patients undergoing MT, which included 27% centers that changed their policy from PI to PNI. There was no significant difference in rate of COVID-19 infection between PI versus PNI centers (p=0.60) or if intubation policy was changed in either direction (p=1.00). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) were less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers were more likely to report them to be inadequate (58% vs 92%). Conclusion Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic. Overall, respondents reported decreased stroke admissions as well as decreased cases of MT with no clear preponderance in intubation policy during MT. Data access statement The corresponding author will consider requests for sharing survey data. The study was exempt from institutional review board approval as it did not involve patient level data.
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Affiliation(s)
- Dileep R Yavagal
- University of Miami Miller School of Medicine, Miami, FL, United States.
| | - Vasu Saini
- University of Miami Miller School of Medicine, Miami, FL, United States
| | - Violiza Inoa
- Semmes-Murphey Clinic, Memphis, TN, United States
| | - Hannah E Gardener
- University of Miami Miller School of Medicine, Miami, FL, United States
| | - Sheila O Martins
- University Federal of Rio Grande do Sul, Hosp de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | | | | | | | | | - Jennifer Potter-Vig
- Society of Vascular and Interventional Neurology, St. Cloud, MN, United States
| | | | | | - P N Sylaja
- Sree Chitra Tirunal Inst for Medical Sciences and Technology, Trivandrum, India
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15
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Abstract
Anesthesiologists provide care to acute and subacute ischemic stroke (IS) patients and stroke survivors in interventional radiology, intensive care, and operating rooms. These encounters will become more frequent following studies that have extended the treatment window from last known well time for fibrinolytic and endovascular thrombectomy (EVT). The number of stroke centers certified to quickly and effectively initiate treatment of IS patients and the number of patients connected to them by telehealth continue to grow. This article reviews IS pathophysiology, assessment, treatment, pathology, and complications; anesthetic management during EVT; perioperative stroke management; and how anesthesia has an impact on patients with prior stroke.
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16
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Tabibian BE, Howell SG, Salehani A, Bakradze E, Harrigan M. Adaptive Approach to Endovascular Management of Large Vessel Occlusion During the COVID-19 Pandemic. J Stroke Cerebrovasc Dis 2021; 30:105642. [PMID: 33607456 PMCID: PMC7846204 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/04/2021] [Accepted: 01/24/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction The COVID-19 pandemic has resulted in unprecedented strain on the health care system. An adaptive strategy for the handling of thrombectomy for patients with large vessel occlusion has evolved at our center to optimize patient care while also minimizing risk of virus transmission. The purpose of this study was to evaluate the effects of the new thrombectomy protocol by comparing thrombectomy times and patient outcomes during the pandemic and pre pandemic period. Methods A retrospective cohort study was conducted on patients who underwent emergent thrombectomy from April 4th, 2020 to August 25th, 2020 (pandemic period) and between December 2nd, 2019 to April 3rd, 2020 (pre-pandemic period). The new protocol centered on a standardized approach to airway management in patients considered ‘high-risk’ for infection. An array of patient-specific factors and outcomes were compared between the two groups. Results A total of 126 patients were included in the study. There was no significant difference in door-to-recanalization or other time parameters between the two groups (138 minutes during the pandemic vs. 129 minutes pre-pandemic; p=0.37). However, outcomes measured as discharge modified Rankin Scale (mRS) were worse for patients during the pandemic (mRS ≤ 2, 10/58; 17.2% during pandemic vs. 24/68; 35.3% pre-pandemic, p = 0.02). No neurointerventional providers have been found to contract COVID-19. Conclusion Our approach to mechanical thrombectomy during the COVID-19 era was associated with similar recanalization rates but worse clinical outcomes compared to pre pandemic period. Further studies are necessary to identify factors contributing to worse outcomes during this ongoing pandemic.
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Affiliation(s)
| | - Sasha G Howell
- University of Alabama at Birmingham, Department of Neurosurgery, Birmingham, AL.
| | - Arsalaan Salehani
- University of Alabama at Birmingham, Department of Neurosurgery, Birmingham, AL
| | - Ekaterina Bakradze
- University of Alabama at Birmingham, Department of Neurosurgery, Birmingham, AL
| | - Mark Harrigan
- University of Alabama at Birmingham, Department of Neurosurgery, Birmingham, AL
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17
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Rikhtegar R, Mosimann PJ, Weber R, Wallocha M, Yamac E, Mirza-Aghazadeh-Attari M, Chapot R. Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events. J Neurointerv Surg 2021; 13:1067-1072. [PMID: 33468609 PMCID: PMC8606433 DOI: 10.1136/neurintsurg-2020-017035] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 12/18/2022]
Abstract
Background Recent progress with smaller retrievers has expanded the ability to reach distal brain arteries. We herein report recanalization, bleeding complications and short-term clinical outcomes with the smallest currently known low profile thrombectomy device in patients with primary or secondary distal medium vessel occlusion (DMVO). Methods We performed a retrospective analysis of 115 patients receiving mechanical thrombectomy (MT) in DMVO using the extended Thrombolysis in Cerebral Infarction (eTICI), European Cooperative Acute Stroke Study (ECASS) II classification, The National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores at admission and discharge to evaluate outcomes. Patients were stratified into three groups: (1) primary isolated distal occlusion (n=34), (2) secondary distal occlusion after MT of a proximal vessel occlusion (n=71), or (3) during endovascular treatment of aneurysms or arteriovenous malformations (AVMs) (n=10). Results Successful distal recanalization, defined as an eTICI score of 2b67, 2c and 3, was achieved in 74.7% (86/115) of patients. More specifically, it was 70.5% (24/34), 73.2% (52/71), and 100% (10/10) of primary DMVO, secondary DMVO after proximal MT, and rescue MT during aneurysm or AVM embolization, respectively. Symptomatic intraparenchymal bleeding occurred in 6.9% (eight patients). In-hospital mortality occurred in 18.1% (19/105) of patients with stroke. The most common cause of death was large infarct, old age, and therapy limitation. Conclusion Direct or rescue MT of DMVO using a very low profile thrombectomy device is associated with a high rate of successful recanalization and a reasonable rate of symptomatic hemorrhagic complication, despite a risk of 18.1% hospital mortality in elderly patients. Further trials are needed to confirm our results and assess long-term clinical outcomes.
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Affiliation(s)
- Reza Rikhtegar
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Pascal John Mosimann
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Ralph Weber
- Department of Neurology, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Marta Wallocha
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Elif Yamac
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | | | - René Chapot
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany
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18
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Abstract
PURPOSE OF REVIEW Abrupt blood pressure (BP) rise is the most common clinical symptom of acute ischemic stroke (AIS). However, BP alterations during AIS reflect many diverse mechanisms, both stroke-related and nonspecific epiphenomena, which change over time and across patients. While extremes of BP as well as high BP variability have been related with worse outcomes in observational studies, optimal BP management after AIS remains challenging. RECENT FINDINGS This review discusses the complexity of the factors linking BP changes to the clinical outcomes of patients with AIS, depending on the treatment strategy and local vessel status and, in particular, the degree of reperfusion achieved. The evidence for possible additional clinical markers, including the presence of arterial hypertension, and comorbid organ dysfunction in individuals with AIS, as informative and helpful factors in therapeutic decision-making concerning BP will be reviewed, as well as recent data on neurovascular monitoring targeting person-specific local cerebral perfusion and metabolic demand, instead of the global traditional parameters (BP among others) alone. The individualization of BP management protocols based on a complex evaluation of the homeostatic response to focal cerebral ischemia, including but not limited to BP changes, may be a valuable novel goal proposed in AIS, but further trials are warranted.
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Affiliation(s)
- Dariusz Gąsecki
- Department of Adult Neurology, Medical University of Gdańsk, ul, Dębinki 7, 80-952, Gdańsk, Poland.
| | - Mariusz Kwarciany
- Department of Adult Neurology, Medical University of Gdańsk, ul, Dębinki 7, 80-952, Gdańsk, Poland
| | - Kamil Kowalczyk
- Department of Adult Neurology, Medical University of Gdańsk, ul, Dębinki 7, 80-952, Gdańsk, Poland
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdańsk, ul, Dębinki 7, 80-952, Gdańsk, Poland
| | - Bartosz Karaszewski
- Department of Adult Neurology, Medical University of Gdańsk, ul, Dębinki 7, 80-952, Gdańsk, Poland
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19
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Pilato F, Silva S, Valente I, Distefano M, Broccolini A, Brunetti V, Caliandro P, Marca GD, Di Iorio R, Frisullo G, Monforte M, Morosetti R, Piano C, Calandrelli R, Capone F, Alexandre A, Pedicelli A, Colosimo C, Caricato A. Predicting Factors of Functional Outcome in Patients with Acute Ischemic Stroke Admitted to Neuro-Intensive Care Unit-A Prospective Cohort Study. Brain Sci 2020; 10:brainsci10120911. [PMID: 33256264 PMCID: PMC7761293 DOI: 10.3390/brainsci10120911] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/16/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023] Open
Abstract
Although thrombectomy is beneficial for most stroke patients with large vessel occlusion (LVO), it has added new issues in acute management due to intensive care support. In this prospective cohort study, we described the patients admitted to our neuro-intensive care unit (NICU) after thrombectomy in order to assess factors linked to functional outcomes. The outcome was independency assessed for stroke patients consecutively admitted to NICU for an ischemic stroke due to LVO of the anterior cerebral circulation that underwent intra-arterial mechanical thrombectomy (IAMT), either in combination with intravenous thrombolysis (IVT) in eligible patients or alone in patients with contraindications for IVT. Overall, 158 patients were enrolled. IVT (odds ratio (OR), 3.78; 95% confidence interval (CI), 1.20–11.90; p = 0.023) and early naso-gastric tube removal (OR, 3.32; 95% CI, 1.04–10.59 p = 0.042) were associated with good outcomes, whereas a high baseline National Institutes of Health Stroke Scale (NIHSS) score (OR, 0.72 for each point of increase; 95% CI, 0.61–0.85; p < 0.001) was a predictor of poor outcomes at 3 months. Older age (OR, 0.95 for each year of increase; 95% CI, 0.92–0.99; p = 0.020) and hemorrhagic transformation (OR, 0.31; 95% CI, 0.11–0.84; p = 0.022) were predictors of poor outcomes after IAMT, whereas a modified Treatment in Cerebral Infarction (mTICI) score of 2b/3 was a predictor of good outcomes (OR, 7.86; 95% CI, 1.65–37.39; p = 0.010) at 6 months. Our results show that acute stroke patients with LVO who require NICU management soon after IAMT may show specific clinical factors influencing short- and long-term neurologic independency.
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Affiliation(s)
- Fabio Pilato
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
- Unit of Neurology, Neurophysiology, Department of Medicine, Università Campus Bio-Medico di Roma, 00128 Rome, Italy;
- Correspondence: ; Tel.: +39-06-30151
| | - Serena Silva
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
| | - Iacopo Valente
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (I.V.); (R.C.); (A.A.); (A.P.); (C.C.)
| | - Marisa Distefano
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Aldobrando Broccolini
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
| | - Valerio Brunetti
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Pietro Caliandro
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Giacomo Della Marca
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
| | - Riccardo Di Iorio
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Giovanni Frisullo
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Mauro Monforte
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Roberta Morosetti
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Carla Piano
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Rosalinda Calandrelli
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
| | - Fioravante Capone
- Unit of Neurology, Neurophysiology, Department of Medicine, Università Campus Bio-Medico di Roma, 00128 Rome, Italy;
| | - Andrea Alexandre
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
| | - Alessandro Pedicelli
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
| | - Cesare Colosimo
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
| | - Anselmo Caricato
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
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20
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Salehani A, Self D, Agee B, Refaey K, Elsayed GA, Chagoya G, Bernstock J, Stetler W. Impact of Anesthetic Variation in Endovascular Treatment of Acute Ischemic Stroke. Cureus 2020; 12:e11328. [PMID: 33304666 PMCID: PMC7719469 DOI: 10.7759/cureus.11328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Given recent technological advancements leading to better outcomes in endovascular therapy for acute ischemic stroke (AIS), updated guidelines recommend thrombectomy as the standard of care in acute large vessel occlusions. However, use of general anesthesia versus conscious sedation continues to be discussed. Two previous randomized trials have shown no significant difference between the use of conscious sedation compared with general anesthesia. Methods The authors performed a retrospective analysis of all consecutive patients with acute ischemia who underwent intra-arterial thrombectomy between September 2014 and May 2020 at a Level 1 stroke center. Patient characteristics along with clinical and operative data were extracted. Frequency distributions of selected characteristics were obtained and statistical significance of any differences according to the mode of anesthesia was assessed. Results A total of 480 patients were included in this study, 257 underwent general anesthesia and 223 underwent conscious sedation. Length of stay (LOS) in the ICU nor length of hospital stay was significantly different between groups. Change in National Institutes of Health Stroke Scale (NIHSS) score from admission to discharge, procedure times, and discharge disposition were not found to be significantly associated with either group although there was a trend towards longer door to puncture time with general anesthesia. Discharge disposition was found to be significantly associated with admission NIHSS (p=0.04). There was a trend towards longer hospital stay in patients with worse admission NIHSS (p=0.09). Success of thrombectomy was not significantly different between both anesthesia groups (p=0.37). Conclusions This large, single-center retrospective cohort study echoes the results of two previous randomized controlled trials in demonstrating non-inferiority of general anesthesia versus conscious sedation in cases of intra-arterial thrombectomy for AIS. These results contrast those of previously published retrospective studies.
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Affiliation(s)
- Arsalaan Salehani
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Dwight Self
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Bonita Agee
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Karim Refaey
- Neurological Surgery, Mayo Clinic, Jacksonville, USA
| | - Galal A Elsayed
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Gustavo Chagoya
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Joshua Bernstock
- Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - William Stetler
- Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, USA
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21
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Gruenbaum SE, Gruenbaum BF, Bertasi RAO, Bertasi TGO, Zlotnik A. Intraoperative management of thrombectomy for acute ischemic stroke: Do we need general anesthesia? Best Pract Res Clin Anaesthesiol 2020; 35:171-179. [PMID: 34030802 DOI: 10.1016/j.bpa.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/07/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
Since 2015, endovascular thrombectomy has been established as the standard of care for re-establishing cerebral blood flow in patients with acute ischemic stroke. Several retrospective observational studies and prospective clinical trials have investigated two anesthetic techniques for endovascular stroke therapy: general anesthesia (GA) and conscious sedation (CS). The recent randomized studies suggest that GA is associated with higher rates of successful recanalization and better functional independence at 3 months compared with the CS technique. However, CS techniques are highly variable, and there is currently a lack of consensus on which anesthetic approach is best in all patients. Numerous patient and procedural factors should ultimately guide the decision of whether GA or CS should be used for a particular patient.
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Affiliation(s)
- Shaun E Gruenbaum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, United States.
| | - Benjamin F Gruenbaum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, United States.
| | - Raphael A O Bertasi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, United States.
| | - Tais G O Bertasi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, United States.
| | - Alexander Zlotnik
- Division of Anesthesiology and Critical Care, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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22
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Hebert S, Clavel P, Maier B, Mizutani K, Delvoye F, Lapergue B, Maacha MB, Fahed R, Escalard S, Desilles JP, Redjem H, Ciccio G, Smajda S, Blanc R, Piotin M, Mazighi M. Benefits and Safety of Periprocedural Heparin During Thrombectomy in Patients Contra-Indicated for Alteplase. J Stroke Cerebrovasc Dis 2020; 29:105052. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 11/28/2022] Open
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23
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Liang F, Zhao Y, Yan X, Wu Y, Li X, Zhou Y, Jian M, Li S, Miao Z, Han R, Peng Y. Choice of ANaesthesia for EndoVAScular treatment of acute ischaemic stroke at posterior circulation (CANVAS II): protocol for an exploratory randomised controlled study. BMJ Open 2020; 10:e036358. [PMID: 32737091 PMCID: PMC7398089 DOI: 10.1136/bmjopen-2019-036358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Observational and interventional studies indicate that the type of anaesthesia may be associated with the postprocedural neurological function in patients with anterior circulation acute ischaemic stroke undergoing endovascular treatment. Patients with acute posterior circulation ischaemic stroke may experience different physiological changes and result in severe neurological outcome. However, the effect of the type of anaesthesia on postprocedure neurological function remained unclear in this population. METHODS AND ANALYSIS This is an exploratory randomised controlled trial that will be carried out at Beijing Tiantan Hospital, Capital Medical University. Patients with acute posterior circulation ischaemic stroke and deemed suitable for emergency endovascular recanalisation will be recruited in this trial. Eighty-four patients will be randomised to receive either general anaesthesia or conscious sedation with 1:1 allocation ratio. The primary endpoint is the 90-day modified Rankin Scale. ETHICS AND DISSEMINATION The study has been reviewed by and approved by Ethics Committee of Beijing Tiantan Hospital of Capital Medical University (KY2017-074-02). If the results are positive, the study will indicate whether the type of anaesthesia affects neurological outcome after endovascular treatment of posterior stroke. The findings of the study will be published in peer-reviewed journals and presented at national or international conferences. TRIAL REGISTRATION NUMBER NCT03317535.
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Affiliation(s)
- Fa Liang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan Zhao
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiang Yan
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxuan Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiuheng Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Zhou
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Minyu Jian
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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24
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The KEEP SIMPLEST Study: Improving In-House Delays and Periinterventional Management in Stroke Thrombectomy-A Matched Pair Analysis. Neurocrit Care 2020; 31:46-55. [PMID: 30659468 DOI: 10.1007/s12028-018-00667-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Although the treatment window for mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) has been extended in recent years, it has been proven that recanalizing treatment must be administered as soon as possible. We present a new standard operating procedure (SOP) to reduce in-house delay, standardize periinterventional management and improve patient safety during MT. METHODS KEep Evaluating Protocol Simplification In Managing Periinterventional Light Sedation for Endovascular Stroke Treatment (KEEP SIMPLEST) was a prospective, single-center observational study aimed to compare aspects of periinterventional management in AIS patients treated according to our new SOP using a combination of esketamine and propofol with patients having been randomized into conscious sedation (CS) in the Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial. Primary outcome was early neurological improvement at 24h using the National Institutes of Health Stroke Scale, and secondary outcomes were door-to-recanalization, recanalization grade, conversion rate and modified Rankin Scale (mRS) at 3 months. RESULTS Door-to-recanalization time (128.6 ± 69.47 min vs. 156.8 ± 75.91 min; p = 0.02), mean duration of MT (92.01 ± 52 min vs. 131.9 ± 64.03 min; p < 0.001), door-to-first angiographic image (51.61 ± 31.7 min vs. 64.23 ± 21.53 min; p = 0.003) and computed tomography-to-first angiographic image time (31.61 ± 20.6 min vs. 44.61 ± 19.3 min; p < 0.001) were significantly shorter in the group treated under the new SOP. There were no differences in early neurological improvement, mRS at 3 months or other secondary outcomes between the groups. Conversion rates of CS to general anesthesia were similar in both groups. CONCLUSION An SOP using a novel sedation regimen and optimization of equipment and procedures directed at a leaner, more integrative and compact periinterventional management can reduce in-house treatment delays significantly in stroke patients receiving thrombectomy in light sedation and demonstrated the safety and feasibility of our improved approach.
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25
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Qureshi AI, Abd-Allah F, Al-Senani F, Aytac E, Borhani-Haghighi A, Ciccone A, Gomez CR, Gurkas E, Hsu CY, Jani V, Jiao L, Kobayashi A, Lee J, Liaqat J, Mazighi M, Parthasarathy R, Miran MS, Steiner T, Toyoda K, Ribo M, Gongora-Rivera F, Oliveira-Filho J, Uzun G, Wang Y. Management of acute ischemic stroke in patients with COVID-19 infection: Insights from an international panel. Am J Emerg Med 2020; 38:1548.e5-1548.e7. [PMID: 32444298 PMCID: PMC7211609 DOI: 10.1016/j.ajem.2020.05.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/06/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To present guidance for clinicians caring for adult patients with acuteischemic stroke with confirmed or suspected COVID-19 infection. METHODS The summary was prepared after review of systematic literature reviews,reference to previously published stroke guidelines, personal files, and expert opinionby members from 18 countries. RESULTS The document includes practice implications for evaluation of stroke patientswith caution for stroke team members to avoid COVID-19 exposure, during clinicalevaluation and conduction of imaging and laboratory procedures with specialconsiderations of intravenous thrombolysis and mechanical thrombectomy in strokepatients with suspected or confirmed COVID-19 infection. RESULTS Conclusions-The summary is expected to guide clinicians caring for adult patientswith acute ischemic stroke who are suspected of, or confirmed, with COVID-19infection.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Foad Abd-Allah
- Department of Neurology, Kasralainy school of Medicine, Cairo University, Cairo, Egypt
| | - Fahmi Al-Senani
- Department of Neurology, National Neurosciences Institute, King Fahad Medical City, Riyadh,Kingdom of Saudi Arabia
| | - Emrah Aytac
- Zeenat Qureshi Stroke Institute,Department of Neurology, University of FIRAT, Elazig Turkey
| | | | - Alfonso Ciccone
- Department of Neurosciences, Hospital Carlo Poma, ASST di Mantova, Mantua, Italy
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, MO, USA
| | - Erdem Gurkas
- Stroke Center, Department of Neurology, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Vishal Jani
- Department of Neurology, Creighton University Medical Center/CHI Health, Omaha, NE, USA.
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Adam Kobayashi
- Department of Neurology and Interventional Stroke Treatment Centre, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Jun Lee
- Department of Neurology, Yeungnam University School of Medicine, Daegu, Korea
| | - Jahanzeb Liaqat
- Department of Neurology, Pak-Emirates Military Hospital, Rwp, Pakistan
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, University of Paris, Laboratory of Vascular Translational Sciences, Paris, France
| | | | | | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Ho¨chst, Frankfurt and Heidelberg University Hospital, Heidelberg, Germany
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain
| | - Fernando Gongora-Rivera
- Servicio de Neurología, Hospital Universitario José Eleuterio González de la Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México; Instituto de Neurología y Neurocirugía, Hospital Zambrano Hellion, Tecnológico de Monterrey, San Pedro, Nuevo León, México
| | | | - Guven Uzun
- Beverly Hills Pain Institute and Neurology, Beverly Hills, CA, USA
| | - Yongjun Wang
- Tiantan Comprehensive Stroke Center, Beijing Tiantan Hospital, Capital Medical University Beijing, China
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Marion JT, Seyedsaadat SM, Pasternak JJ, Rabinstein AA, Kallmes DF, Brinjikji W. Association of local anesthesia versus conscious sedation with functional outcome of acute ischemic stroke patients undergoing embolectomy. Interv Neuroradiol 2020; 26:396-404. [PMID: 32375517 DOI: 10.1177/1591019920923831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Compare functional outcomes of acute ischemic stroke patients undergoing embolectomy with either local anesthesia or conscious sedation. Secondarily, identify differences in hemodynamic parameters and complication rates between groups. MATERIALS AND METHODS Single institution, retrospective review of all acute ischemic stroke patients undergoing embolectomy between January 2014 and July 2018 (n = 185). Patients receiving general anesthesia (n = 27) were excluded. One-hundred and eleven of 158 (70.3%) composed the local anesthesia group, and 47 (29.7%) composed the conscious sedation group. Median age was 71 years (interquartile range 59-79). Seventy-eight (49.4%) were male. The median National Institute of Health stroke scale score was 17.5 (interquartile range 11-21). Hemodynamic, medication, complication, and functional outcome data were collected from the anesthesia protocol and medical records. Good functional outcome was defined as a three-month modified Rankin Scale < 2. A multivariate analysis was performed to estimate the association of anesthesia type on three-month modified Rankin Scale score. RESULTS Three-month modified Rankin Scale score <2 was similar between groups (p = 0.5). Patients receiving conscious sedation were on average younger than patients receiving local anesthesia (p = 0.01). Conscious sedation patients were more likely to receive intravenous thrombolytic prior to embolectomy (p = 0.025). The complication rate and hemodynamic parameters were similar between groups. CONCLUSION Functional outcome of acute ischemic stroke patients undergoing embolectomy appears to be similar for patients receiving local anesthesia and conscious sedation. This similarity may be beneficial to a future study comparing general anesthesia to local anesthesia and conscious sedation. The use of local anesthesia or conscious sedation does not significantly impact hemodynamic status.
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27
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Qureshi AI, Abd-Allah F, Al-Senani F, Aytac E, Borhani-Haghighi A, Ciccone A, Gomez CR, Gurkas E, Hsu CY, Jani V, Jiao L, Kobayashi A, Lee J, Liaqat J, Mazighi M, Parthasarathy R, Steiner T, Suri MFK, Toyoda K, Ribo M, Gongora-Rivera F, Oliveira-Filho J, Uzun G, Wang Y. Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel. Int J Stroke 2020; 15:540-554. [DOI: 10.1177/1747493020923234] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and purpose On 11 March 2020, World Health Organization (WHO) declared the COVID-19 infection a pandemic. The risk of ischemic stroke may be higher in patients with COVID-19 infection similar to those with other respiratory tract infections. We present a comprehensive set of practice implications in a single document for clinicians caring for adult patients with acute ischemic stroke with confirmed or suspected COVID-19 infection. Methods The practice implications were prepared after review of data to reach the consensus among stroke experts from 18 countries. The writers used systematic literature reviews, reference to previously published stroke guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate practice implications. All members of the writing group had opportunities to comment in writing on the practice implications and approved the final version of this document. Results This document with consensus is divided into 18 sections. A total of 41 conclusions and practice implications have been developed. The document includes practice implications for evaluation of stroke patients with caution for stroke team members to avoid COVID-19 exposure, during clinical evaluation and performance of imaging and laboratory procedures with special considerations of intravenous thrombolysis and mechanical thrombectomy in stroke patients with suspected or confirmed COVID-19 infection. Conclusions These practice implications with consensus based on the currently available evidence aim to guide clinicians caring for adult patients with acute ischemic stroke who are suspected of, or confirmed, with COVID-19 infection. Under certain circumstances, however, only limited evidence is available to support these practice implications, suggesting an urgent need for establishing procedures for the management of stroke patients with suspected or confirmed COVID-19 infection.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Foad Abd-Allah
- Department of Neurology, Kasralainy school of Medicine, Cairo University, Cairo, Egypt
| | - Fahmi Al-Senani
- Neurology Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Emrah Aytac
- Department of Neurology, University of FIRAT, Elazig Turkey
| | | | - Alfonso Ciccone
- Department of Neurosciences, Hospital Carlo Poma, ASST di Mantova, Mantua, Italy
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, MO, USA
| | - Erdem Gurkas
- Stroke Center, Department of Neurology, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Vishal Jani
- Department of Neurology, Creighton University Medical Center/CHI Health, Omaha, NE, USA
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Adam Kobayashi
- Department of Neurology and Interventional Stroke Treatment Centre, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Jun Lee
- Department of Neurology, Yeungnam University School of Medicine, Daegu, Korea
| | - Jahanzeb Liaqat
- Pakistan Emirates Military Hospital (J.L.), Rawalpindi, Pakistan
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, University of Paris, Laboratory of Vascular Translational Sciences, Paris, France
| | | | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt and Heidelberg University Hospital, Heidelberg, Germany
| | | | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain
| | - Fernando Gongora-Rivera
- Servicio de Neurología, Hospital Universitario José Eleuterio González de la Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México; Instituto de Neurología y Neurocirugía, Hospital Zambrano Hellion, Tecnológico de Monterrey, San Pedro, Nuevo León, México
| | | | - Guven Uzun
- Beverly Hills Pain Institute and Neurology, Beverly Hills, CA, USA
| | - Yongjun Wang
- Tiantan Comprehensive Stroke Center, Beijing Tiantan Hospital, Capital Medical University Beijing, China
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Ren C, Xu G, Liu Y, Liu G, Wang J, Gao J. Effect of Conscious Sedation vs. General Anesthesia on Outcomes in Patients Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke: A Prospective Randomized Clinical Trial. Front Neurol 2020; 11:170. [PMID: 32265821 PMCID: PMC7105779 DOI: 10.3389/fneur.2020.00170] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 02/24/2020] [Indexed: 01/05/2023] Open
Abstract
Background: Although several studies have compared conscious sedation (CS) with general anesthesia (GA) in patients undergoing mechanical thrombectomy (MT), there has been no affirmative conclusion. We conducted this trial to assess whether CS is superior to GA for patients undergoing MT for acute ischemic stroke (AIS). Methods: Acute ischemic stroke patients with anterior circulation large vascular occlusion were randomized into two groups. The primary outcome was modified Rankin scale score (0–2) at 90 days after stroke. Secondary outcomes included intraprocedural hemodynamics, time metrics, successful recanalization, neurointerventionalist satisfaction score, National Institutes of Health Stroke Scale (NIHSS) score, and Alberta Stroke Program Early CT Score (ASPECTS) at 48 h post-intervention, mortality at discharge and 3 months after stroke, and complications. Results: Compared with the CS group, heart rate was significantly lower at T1–T8 in the GA group except at T4 (P < 0.05). Mean arterial pressure (MAP) and systolic blood pressure were significantly lower in the GA group at T4–T6 and T9 (P < 0.05). Pulse oxygen saturation was significantly higher at T2–T9 in the GA group (P < 0.05). There were no significant differences in time metrics, vasoactive drug use, occurrence of >20% fall in MAP, pre-recanalization time spent with >20% fall in MAP, neurointerventionalist satisfaction, successful recanalization rate, NIHSS, and ASPECTS scores at 48 h post-intervention, and mortality rate at discharge and 3 months after stroke (P > 0.05). The cerebral infarction rate at 30 days was greater in the CS group, but not significantly (P > 0.05). There were no differences in complication rates except for pneumonia (P > 0.05). Conversion rate from CS to GA was 9.52%. Conclusion: Anesthetic management with GA or CS during MT had no differential impact on the functional outcomes and mortality at discharge or 3 months after stroke in AIS patients, but CS led to more stable hemodynamics and lower incidence of pneumonia.
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Affiliation(s)
- Chunguang Ren
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Guangjun Xu
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Yanchao Liu
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Guoying Liu
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Jinping Wang
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Jian Gao
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, China
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Hindman BJ. Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 1: Patient Characteristics, Determinants of Effectiveness, and Effect of Blood Pressure on Outcome. Anesth Analg 2019; 128:695-705. [PMID: 30883415 DOI: 10.1213/ane.0000000000004044] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the United States, stroke ranks fifth among all causes of death and is the leading cause of serious long-term disability. 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 within 6 hours of symptom onset or within 6-24 hours 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 patients treated with endovascular thrombectomy. Part 1 (this article) reviews the development of endovascular thrombectomy and the determinants of endovascular thrombectomy effectiveness irrespective of method of anesthesia. The first aim of part 1 is to explain why rapid workflow and maintenance of blood pressure are necessary to help support the ischemic brain until, as a result of endovascular thrombectomy, reperfusion is accomplished. The second aim of part 1, understanding the nonanesthesia factors determining endovascular thrombectomy effectiveness, is necessary to identify numerous biases present in observational reports regarding anesthesia for endovascular thrombectomy. With this background, in part 2 (the companion to this article), the observational literature is briefly summarized, largely to identify its weaknesses, but also to develop hypotheses derived from it that have been recently tested in 3 randomized clinical trials of sedation versus general anesthesia for endovascular thrombectomy. In part 2, these 3 trials are reviewed both from a functional outcomes perspective (meta-analysis) and a methodological perspective, providing specifics regarding anesthesia and hemodynamic management. Part 2 concludes with a pragmatic approach to anesthesia decision making (sedation versus general anesthesia) and acute phase anesthesia management of patients treated with endovascular thrombectomy.
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Affiliation(s)
- Bradley J Hindman
- From the Department of Anesthesia, The University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
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Hindman BJ, Dexter F. Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 2: Integrating and Applying Observational Reports and Randomized Clinical Trials. Anesth Analg 2019; 128:706-717. [PMID: 30883416 DOI: 10.1213/ane.0000000000004045] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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.
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Affiliation(s)
- Bradley J Hindman
- From the Department of Anesthesia, The University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
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31
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Weyland CS, Hemmerich F, Möhlenbruch MA, Bendszus M, Pfaff JAR. Radiation exposure and fluoroscopy time in mechanical thrombectomy of anterior circulation ischemic stroke depending on the interventionalist’s experience—a retrospective single center experience. Eur Radiol 2019; 30:1564-1570. [DOI: 10.1007/s00330-019-06482-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/10/2019] [Accepted: 10/09/2019] [Indexed: 12/21/2022]
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32
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Site of Occlusion May Influence Decision to Perform Thrombectomy Under General Anesthesia or Conscious Sedation. J Neurosurg Anesthesiol 2019; 33:147-153. [PMID: 31567854 DOI: 10.1097/ana.0000000000000642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/31/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although mechanical thrombectomy has become the standard of care for large-vessel occlusion, the role of conscious sedation versus general anesthesia (GA) with intubation during thrombectomy remains controversial. Aphasia may increase patient agitation or apparent uncooperativeness/confusion and thereby lead to higher use of GA. The purpose of this study was to identify risk factors for GA and determine if the side of vessel occlusion potentially impacts GA rates. MATERIALS AND METHODS Patients who underwent mechanical thrombectomy of the middle cerebral artery (MCA) for acute ischemic stroke at our institution between April 2014 and July 2017 were retrospectively reviewed. Patient characteristics, procedural factors, and outcomes were assessed using multivariate regression analyses. Mediation analysis was utilized to investigate whether aphasia lies on the causal pathway between left-sided MCA stroke and GA. RESULTS Overall, 112 patients were included: 62 with left-sided and 50 with right-sided MCA occlusion. Patients with left-sided MCA occlusion presented with aphasia significantly more often those with right-sided occlusion (90.3% vs. 32.0%; P<0.001). GA rates were significantly higher for patients with left-sided compared with right-sided MCA occlusion (45.2% vs. 20.0%; P=0.028). Aphasia mediated 91.3% of the effect of MCA stroke laterality on GA (P=0.02). GA was associated with increased door-to-groin-puncture time (106.4% increase; 95% confidence interval, 24.1%-243.4%; P=0.006) and adverse discharge outcome (odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P=0.019). CONCLUSIONS Patients who had a stroke with left-sided MCA occlusion are more likely to undergo GA for mechanical thrombectomy than those with right-sided MCA occlusion. Aphasia may mediate this effect and understanding this relationship may decrease GA rates through modification of management protocols, potentially leading to improved clinical outcomes. Our study suggests that GA should preferentially be considered for the subset of patients with acute ischemic stroke undergoing mechanical thrombectomy for left-sided MCA occlusion.
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Zimmermann G, Kieser M, Bathke AC. Sample size calculation and blinded recalculation for analysis of covariance models with multiple random covariates. J Biopharm Stat 2019; 30:143-159. [PMID: 31327284 DOI: 10.1080/10543406.2019.1632871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
When testing for superiority in a parallel-group setting with a continuous outcome, adjusting for covariates is usually recommended. For this purpose, the analysis of covariance is frequently used, and recently several exact and approximate sample size calculation procedures have been proposed. However, in case of multiple covariates, the planning might pose some practical challenges and pitfalls. Therefore, we propose a method, which allows for blinded re-estimation of the sample size during the course of the trial. Simulations confirm that the proposed method provides reliable results in many practically relevant situations, and applicability is illustrated by a real-life data example.
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Affiliation(s)
- Georg Zimmermann
- Department of Mathematics, Paris Lodron University, Salzburg, Austria.,Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria.,Spinal Cord Injury and Tissue Regeneration Centre Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Arne C Bathke
- Department of Mathematics, Paris Lodron University, Salzburg, Austria.,Department of Statistics, University of Kentucky, Lexington, KY, USA
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Alrashed A, Dmytriw AA, Yang VXD. Emergent cervical internal carotid artery angioplasty before endovascular thrombectomy for acute ischemic stroke: a report of clinical and imaging outcome. Clin Imaging 2018; 54:48-52. [PMID: 30530099 DOI: 10.1016/j.clinimag.2018.11.014] [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: 05/03/2018] [Revised: 11/10/2018] [Accepted: 11/30/2018] [Indexed: 11/25/2022]
Abstract
A case of tandem occlusion consisting of right internal carotid artery (ICA) origin dissection and middle cerebral artery (MCA) thromoboembolism is reported. A 45 year-old male with right-sided neurological symptoms of emergent large vessel occlusion was treated with same-session angioplasty and mechanical thrombectomy of the respective lesions. The complete neurological recovery and radiological investigations are chronicled herein, and a review of the state of tandem occlusion management is discussed.
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Affiliation(s)
- Abdullah Alrashed
- Neurointervention Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Adam A Dmytriw
- Neurointervention Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, 263 McCaul, St., Toronto, ON M5T 1W5, Canada.
| | - Victor X D Yang
- Neurointervention Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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35
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Dinsmore J, Elwishi M, Kailainathan P. Anaesthesia for endovascular thrombectomy. BJA Educ 2018; 18:291-299. [PMID: 33456793 DOI: 10.1016/j.bjae.2018.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2018] [Indexed: 01/01/2023] Open
Affiliation(s)
- J Dinsmore
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - M Elwishi
- St George's University Hospitals NHS Foundation Trust, London, UK
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36
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Abstract
We provide a synopsis of innovative research, recurring themes, and novel experimental findings pertinent to the care of neurosurgical patients and critically ill patients with neurological diseases. We cover the following broad topics: general neurosurgery, spine surgery, stroke, traumatic brain injury, monitoring, and anesthetic neurotoxicity.
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37
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Schönenberger S, Uhlmann L, Ungerer M, Pfaff J, Nagel S, Klose C, Bendszus M, Wick W, Ringleb PA, Kieser M, Möhlenbruch MA, Bösel J. Association of Blood Pressure With Short- and Long-Term Functional Outcome After Stroke Thrombectomy: Post Hoc Analysis of the SIESTA Trial. Stroke 2018; 49:1451-1456. [PMID: 29720440 DOI: 10.1161/strokeaha.117.019709] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/16/2018] [Accepted: 03/22/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Outcome after mechanical thrombectomy for ischemic stroke may be influenced by blood pressure (BP). This study aims to assess the association of BP changes during general anesthesia versus conscious sedation with functional outcome after mechanical thrombectomy. METHODS SIESTA (Sedation vs Intubation for Endovascular Stroke Treatment) was a monocentric randomized trial of general anesthesia versus conscious sedation during mechanical thrombectomy involving BP target protocols. In this post hoc analysis, BP measurements were divided into 4 phases: preintervention, prerecanalization, postrecanalization, and postintervention. We examined the association between BP and functional outcomes (defined by improvement of 24-hour National Institutes of Health Stroke Scale [NIHSS] and 3-month modified Rankin Scale). RESULTS We found no association between the difference in systolic BP, diastolic BP, and mean arterial pressure from baseline to the different phases of intervention and NIHSS change after 24 hours. Only baseline diastolic BP was associated with a reduced improvement in NIHSS (β=0.17, P<0.01). There was no association of BP drops with a change in modified Rankin Scale at 3 months. About sedation, only baseline mean arterial pressure preintervention revealed significant associations (β=0.16, P<0.01) with less change in 24-hour NIHSS in conscious sedation group. Otherwise, there was no association for differences of any of the BP measurements with a change in 24-hour NIHSS and long-term functional outcome either in general anesthesia or the conscious sedation group when analyzed separately, consistent with our findings in the entire cohort. Doses of propofol (β=0.84, P=0.04) and norepinephrine (β=1.87, P=0.01) administered during intervention before recanalization were associated with reduced improvement of NIHSS at 24 hours. CONCLUSIONS In a setting, where both sedation regimes general anesthesia and conscious sedation were performed according to strict protocols directed at avoiding BP extremes, our findings suggest that peri-interventional BP drops were not associated with either early neurological improvement or long-term functional outcome. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02126085.
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Affiliation(s)
| | - Lorenz Uhlmann
- Department of Medical Biometry, Institute of Medical Biometry and Informatics, University of Heidelberg, Germany (L.U., C.K., M.K.)
| | - Matthias Ungerer
- From the Department of Neurology (S.S., M.U., S.N., W.W., P.A.R., J.B.)
| | - Johannes Pfaff
- Department of Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Simon Nagel
- From the Department of Neurology (S.S., M.U., S.N., W.W., P.A.R., J.B.)
| | - Christina Klose
- Department of Medical Biometry, Institute of Medical Biometry and Informatics, University of Heidelberg, Germany (L.U., C.K., M.K.)
| | - Martin Bendszus
- Department of Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Wolfgang Wick
- From the Department of Neurology (S.S., M.U., S.N., W.W., P.A.R., J.B.)
| | - Peter A Ringleb
- From the Department of Neurology (S.S., M.U., S.N., W.W., P.A.R., J.B.)
| | - Meinhard Kieser
- Department of Medical Biometry, Institute of Medical Biometry and Informatics, University of Heidelberg, Germany (L.U., C.K., M.K.)
| | - Markus A Möhlenbruch
- Department of Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Julian Bösel
- From the Department of Neurology (S.S., M.U., S.N., W.W., P.A.R., J.B.).,Department of Neurology, Klinikum Kassel, Heidelberg, Germany (J.B.)
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38
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Quality and safety in endovascular therapy for acute ischemic stroke. ACTA ACUST UNITED AC 2018; 65:329-334. [PMID: 29571729 DOI: 10.1016/j.redar.2018.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 11/20/2022]
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39
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Pfaff JAR, Schönenberger S, Nagel S, Ringleb PA, Hacke W, Bendszus M, Bösel J, Möhlenbruch MA. Effect of General Anesthesia versus Conscious Sedation for Stroke Thrombectomy on Angiographic Workflow in a Randomized Trial: A Post Hoc Analysis of the SIESTA Trial. Radiology 2018; 286:1016-1021. [DOI: 10.1148/radiol.2017171002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Johannes A. R. Pfaff
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Silvia Schönenberger
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Simon Nagel
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Peter A. Ringleb
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Werner Hacke
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Martin Bendszus
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Julian Bösel
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Markus Alfred Möhlenbruch
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
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Romero Kräuchi O, Valencia L, Iturri F, Mariscal Ortega A, López Gómez A, Valero R. National survey on perioperative anaesthetic management in the endovascular treatment of acute ischaemic stroke. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:13-23. [PMID: 28923240 DOI: 10.1016/j.redar.2017.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 07/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To assess the anaesthetic management of treatment for endovascular acute ischaemic stroke (AIS) in Spain. MATERIALS AND METHOD A survey was designed by the SEDAR Neuroscience Section and sent to the Spanish anaesthesiology departments with a primary stroke centre between July and November 2016. RESULTS Of the 47 hospitals where endovascular treatment of AIS is performed, 37 anaesthesiology departments participated. Thirty responses were obtained; three of which were eliminated due to duplication (response rate of 72.9%). Health coverage for AIS endovascular treatment was available 24hours a day in 63% of the hospitals. The anaesthesiologist in charge of the procedure was physically present in the hospital in 55.3%. There was large inter-hospital variability in non-standard monitoring and type of anaesthesia. The most important criterion for selecting type of anaesthesia was multidisciplinary choice made by the anaesthesiologist, neurologist and neuroradiologist (59.3%). The duration of time from arrival to arterial puncture was 10-15minutes in 59.2%. In 44.4%, systolic blood pressure was maintained between 140-180mmHg, and diastolic blood pressure<105mmHg. Glycaemic levels were taken in 81.5% of hospitals. Intravenous heparinisation was performed during the procedure in 66.7% with different patterns of action. In cases of moderate neurological deterioration with no added complications, 85.2% of the included hospitals awakened and extubated the patients. CONCLUSIONS The wide variability observed in the anaesthetic management and the organization of the endovascular treatment of AIS demonstrates the need to create common guidelines for anaesthesiologists in Spain.
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Affiliation(s)
- O Romero Kräuchi
- Servicio de Anestesiología, Hospital Universitario de Son Espases, Palma de Mallorca, España.
| | - L Valencia
- Servicio de Anestesiología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, España
| | - F Iturri
- Servicio de Anestesiología, Hospital Universitario Cruces, Bilbao, Vizcaya, España
| | - A Mariscal Ortega
- Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A López Gómez
- Servicio de Anestesiología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - R Valero
- Servicio de Anestesiología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
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41
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Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke. J Neurosurg Anesthesiol 2017; 28:214-32. [PMID: 26368664 DOI: 10.1097/ana.0000000000000225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Acute ischemic stroke (AIS) is a devastating condition with high morbidity and mortality. In the past 2 decades, the treatment of AIS has been revolutionized by the introduction of several interventions supported by class I evidence-care on a stroke unit, intravenous tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased. This review highlights the main challenges in the endovascular and intensive care management of AIS that, in part, result from the paucity of research focused on these areas. It also provides guidelines for the management of AIS based upon current evidence, and identifies areas for further research.
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Schönenberger S, Wick W, Bösel J. [Anesthesia for thrombectomy]. Anaesthesist 2017; 66:714-716. [PMID: 28681071 DOI: 10.1007/s00101-017-0342-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- S Schönenberger
- Sektion Akut- und Intensivneurologie, Neurologische Klinik und Poliklinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69121, Heidelberg, Deutschland
| | - W Wick
- Sektion Akut- und Intensivneurologie, Neurologische Klinik und Poliklinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69121, Heidelberg, Deutschland
| | - J Bösel
- Sektion Akut- und Intensivneurologie, Neurologische Klinik und Poliklinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69121, Heidelberg, Deutschland.
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Bekelis K, Missios S, MacKenzie TA, O'Shaughnessy PM. Does Objective Quality of Physicians Correlate with Patient Satisfaction Measured by Hospital Compare Metrics in New York State? World Neurosurg 2017; 103:852-858.e1. [PMID: 28456743 PMCID: PMC5533592 DOI: 10.1016/j.wneu.2017.04.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/15/2017] [Accepted: 04/17/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is unclear whether publicly reported benchmarks correlate with quality of physicians and institutions. We investigated the association of patient satisfaction measures from a public reporting platform with performance of neurosurgeons in New York State. METHODS This cohort study comprised patients undergoing neurosurgical operations from 2009 to 2013 who were registered in the Statewide Planning and Research Cooperative System database. The cohort was merged with publicly available data from the Centers for Medicare and Medicaid Services Hospital Compare website. Propensity-adjusted regression analysis was used to investigate the association of patient satisfaction metrics with neurosurgeon quality, as measured by the neurosurgeon's individual rate of mortality and average length of stay. RESULTS During the study period, 166,365 patients underwent neurosurgical procedures. Using propensity-adjusted multivariable regression analysis, we demonstrated that undergoing neurosurgical operations in hospitals with a greater percentage of patient-assigned "high" scores was associated with higher chance of being treated by a physician with superior performance in terms of mortality (odds ratio 1.90, 95% confidence interval 1.86-1.95), and a higher chance of being treated by a physician with superior performance in terms of length of stay (odds ratio 1.24, 95% confidence interval 1.21-1.27). Similar associations were identified for hospitals with a higher percentage of patients who claimed they would recommend these institutions to others. CONCLUSIONS Merging a comprehensive all-payer cohort of neurosurgery patients in New York State with data from the Hospital Compare website, we observed an association of superior hospital-level patient satisfaction measures with objective performance of individual neurosurgeons in the corresponding hospitals.
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Affiliation(s)
- Kimon Bekelis
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA; Population Health Research Institute of New York at Catholic Health Services of Long Island, Rockville Centre, New York, USA.
| | - Symeon Missios
- Center for Neuro and Spine, Cleveland Clinic-Akron General Hospital, Akron, Ohio, USA
| | - Todd A MacKenzie
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA; Population Health Research Institute of New York at Catholic Health Services of Long Island, Rockville Centre, New York, USA; Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Patrick M O'Shaughnessy
- Population Health Research Institute of New York at Catholic Health Services of Long Island, Rockville Centre, New York, USA
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Schönenberger S, Pfaff J, Uhlmann L, Klose C, Nagel S, Ringleb PA, Hacke W, Kieser M, Bendszus M, Möhlenbruch MA, Bösel J. The Impact of Conscious Sedation versus General Anesthesia for Stroke Thrombectomy on the Predictive Value of Collateral Status: A Post Hoc Analysis of the SIESTA Trial. AJNR Am J Neuroradiol 2017; 38:1580-1585. [PMID: 28596192 DOI: 10.3174/ajnr.a5243] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/17/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Radiologic selection criteria to identify patients likely to benefit from endovascular stroke treatment are still controversial. In this post hoc analysis of the recent randomized Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial, we aimed to investigate the impact of sedation mode (conscious sedation versus general anesthesia) on the predictive value of collateral status. MATERIALS AND METHODS Using imaging data from SIESTA, we assessed collateral status with the collateral score of Tan et al and graded it from absent to good collaterals (0-3). We examined the association of collateral status with 24-hour improvement of the NIHSS score, infarct volume, and mRS at 3 months according to the sedation regimen. RESULTS In a cohort of 104 patients, the NIHSS score improved significantly in patients with moderate or good collaterals (2-3) compared with patients with no or poor collaterals (0-1) (P = .011; mean, -5.8 ± 7.6 versus -1.1 ± 10.7). Tan 2-3 was also associated with significantly higher ASPECTS before endovascular stroke treatment (median, 9 versus 7; P < .001) and smaller mean infarct size after endovascular stroke treatment (median, 35.0 versus 107.4; P < .001). When we differentiated the population according to collateral status (0.1 versus 2.3), the sedation modes conscious sedation and general anesthesia were not associated with significant differences in the predictive value of collateral status regarding infarction size or functional outcome. CONCLUSIONS The sedation mode, conscious sedation or general anesthesia, did not influence the predictive value of collaterals in patients with large-vessel occlusion anterior circulation stroke undergoing thrombectomy in the SIESTA trial.
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Affiliation(s)
- S Schönenberger
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - J Pfaff
- Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - L Uhlmann
- Institute of Medical Biometry and Informatics (L.U., C.K., M.K.), University of Heidelberg, Heidelberg, Germany
| | - C Klose
- Institute of Medical Biometry and Informatics (L.U., C.K., M.K.), University of Heidelberg, Heidelberg, Germany
| | - S Nagel
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - P A Ringleb
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - W Hacke
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - M Kieser
- Institute of Medical Biometry and Informatics (L.U., C.K., M.K.), University of Heidelberg, Heidelberg, Germany
| | - M Bendszus
- Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - M A Möhlenbruch
- Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - J Bösel
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
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45
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Peng Y, Li Y, Jian M, Liu X, Sun J, Jia B, Dong J, Zeng M, Lin N, Zhang L, Gelb AW, Chan MTV, Han R. Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic Stroke: Protocol for a randomized controlled (CANVAS) trial. Int J Stroke 2017; 12:991-997. [PMID: 28436307 DOI: 10.1177/1747493017706243] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Observational studies indicate that the type of anesthesia, local or general, may be associated with the post-procedural neurological function in patients with acute ischemic stroke undergoing endovascular treatment. However, these results need further confirmation, and the causal relationship has not yet been established. Methods This is a randomized controlled equivalence trial. Permuted block randomization stratified by culprit vessels will be used. Six hundred and forty patients with acute ischemic stroke undergoing endovascular recanalization will be randomized one to one to receive either general anesthesia or local anesthesia. The primary endpoint is the modified Rankin scale at 90 days after endovascular treatment. The secondary endpoints are the peri-procedural mortality and morbidity. Discussion The study aims to determine the effects of anesthetic choice on neurological outcomes in patients with acute ischemic stroke undergoing intra-arterial recanalization. If the results are positive, the study will indicate that the type of anesthesia does not affect neurological outcome after endovascular treatment. Trial registration: ClinicalTrial.gov identifier: NCT02677415
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Affiliation(s)
- Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Yan Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Minyu Jian
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Jian Sun
- Department of Anesthesiology, Beijing Fuxing Hospital, Capital Medical University, Beijing, PR China
| | - Bo Jia
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Jia Dong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Nan Lin
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Li Zhang
- Division of Hematology and Medical Oncology, Department of Medicine, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Adrian W. Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew TV Chan
- Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
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46
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Mokin M, Primiani CT, Ren Z, Kan P, Duckworth E, Turner RD, Turk AS, Fargen KM, Dabus G, Linfante I, Dumont TM, Brasiliense LBC, Shallwani H, Snyder KV, Siddiqui AH, Levy EI. Endovascular Treatment of Middle Cerebral Artery M2 Occlusion Strokes: Clinical and Procedural Predictors of Outcomes. Neurosurgery 2017; 81:795-802. [DOI: 10.1093/neuros/nyx060] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 01/23/2017] [Indexed: 11/14/2022] Open
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47
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Redgrave J, Ellis H, Eapen G. Interventional therapies in stroke management: anaesthetic and critical care implications. BJA Educ 2017. [DOI: 10.1093/bjaed/mkw039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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48
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Schönenberger S, Bösel J. Reply from Schönenberger et al. to the letter from Kofke and Sharma regarding "Sedation vs. Intubation for Endovascular Stroke TreAtment (SIESTA) - a randomized monocentric trial". Int J Stroke 2016; 11:NP73. [PMID: 27006424 DOI: 10.1177/1747493016641117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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49
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Welch TL, Pasternak JJ. The Anesthetic Management of Interventional Procedures for Acute Ischemic Stroke. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0166-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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50
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Lahiri S, Schlick K, Kavi T, Song S, Moheet AM, Yusufali T, Rosengart A, Alexander MJ, Lyden PD. Optimizing Outcomes for Mechanically Ventilated Patients in an Era of Endovascular Acute Ischemic Stroke Therapy. J Intensive Care Med 2016; 32:467-472. [PMID: 27543141 DOI: 10.1177/0885066616663168] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Endovascular mechanical thrombectomy is a new standard of care for acute ischemic stroke (AIS). The majority of these patients receive mechanical ventilation (MV), which has been associated with poor outcomes. The implication of this is significant, as most neurointerventionalists prefer general compared to local anesthesia during the procedure. Consequences of hemodynamic and respiratory perturbations during general anesthesia and MV are thought to contribute significantly to the poor outcomes that are encountered. In this review, we first describe the unique risks associated with MV in the specific context of AIS and then discuss evidence of brain goal-directed approaches that may mitigate these risks. These strategies include an individualized approach to hemodynamic parameters (eg, adherence to a minimum blood pressure goal and adequate volume resuscitation), respiratory parameters (eg, arterial carbon dioxide optimization), and the use of ventilator settings that optimize neurological outcomes (eg, arterial oxygen optimization).
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Affiliation(s)
- Shouri Lahiri
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,2 Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Konrad Schlick
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tapan Kavi
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shlee Song
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Asma M Moheet
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,2 Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Taizoon Yusufali
- 3 Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Axel Rosengart
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,2 Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael J Alexander
- 2 Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Patrick D Lyden
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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