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Farooqui M, Galecio-Castillo M, Hassan AE, Divani AA, Jumaa M, Ribo M, Petersen NH, Abraham MG, Fifi JT, Guerrero WR, Malik A, Siegler JE, Nguyen TN, Sheth SA, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Tekle WG, Sabbagh SY, Zaidi SF, Olive Gadea M, Prasad A, Qureshi A, De Leacy RA, Abdalkader M, Salazar-Marioni S, Soomro J, Gordon W, Turabova C, Rodriguez-Calienes A, Vivanco-Suarez J, Mokin M, Yavagal DR, Jovin TG, Ortega-Gutierrez S. Anesthetic management for large vessel occlusion acute ischemic stroke with tandem lesions. J Neurointerv Surg 2024:jnis-2023-021360. [PMID: 38429099 DOI: 10.1136/jnis-2023-021360] [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: 12/11/2023] [Accepted: 02/13/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Endovascular therapy (EVT) stands as an established and effective intervention for acute ischemic stroke in patients harboring tandem lesions (TLs). However, the optimal anesthetic strategy for EVT in TL patients remains unclear. This study aims to evaluate the impact of distinct anesthetic techniques on outcomes in acute ischemic stroke patients presenting with TLs. METHODS Patient-level data, encompassing cases from 16 diverse centers, were aggregated for individuals with anterior circulation TLs treated between January 2015 and December 2020. A stratification based on anesthetic technique was conducted to distinguish between general anesthesia (GA) and procedural sedation (PS). Multivariable logistic regression models were built to discern the association between anesthetic approach and outcomes, including the favorable functional outcome defined as 90-day modified Rankin Score (mRS) of 0-2, ordinal shift in mRS, symptomatic intracranial hemorrhage (sICH), any hemorrhage, successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b), excellent recanalization (mTICI 3), first pass effect (FPE), early neurological improvement (ENI), door-to-groin and recanalization times, intrahospital mortality, and 90-day mortality. RESULTS Among 691 patients from 16 centers, 595 patients (GA 38.7%, PS 61.3%) were included in the final analysis. There were no significant differences noted in the door-to-groin time (80 (46-117.5) mins vs 54 (21-100), P=0.607) and groin to recanalization time (59 (39.5-85.5) mins vs 54 (38-81), P=0.836) among the groups. The odds of a favorable functional outcome (36.6% vs 52.6%; adjusted OR (aOR) 0.56, 95% CI 0.38 to 0.84, P=0.005) and a favorable shift in the 90-day mRS (aOR 0.71, 95% CI 0.51 to 0.99, P=0.041) were lower in the GA group. No differences were noted for sICH (3.9% vs 4.7%, P=0.38), successful recanalization (89.1% vs 86.5%, P=0.13), excellent recanalization (48.5% vs 50.3%, P=0.462), FPE (53.6% vs 63.4%, P=0.05), ENI (38.9% vs 38.8%, P=0.138), and 90-day mortality (20.3% vs 16.3%, P=0.525). An interaction was noted for favorable functional outcome between the type of anesthesia and the baseline Alberta Stroke Program Early CT Score (ASPECTS) (P=0.033), degree of internal carotid artery (ICA) stenosis (P<0.001), and ICA stenting (P<0.001), and intraparenchymal hematoma between the type of anesthesia and intravenous thrombolysis (P=0.019). In a subgroup analysis, PS showed better functional outcomes in patients with age ≤70 years, National Institutes of Health Stroke Scale (NIHSS) score <15, and acute ICA stenting. CONCLUSIONS Our findings suggest that the preference for PS not only aligns with comparable procedural safety but is also associated with superior functional outcomes. These results prompt a re-evaluation of current anesthesia practices in EVT, urging clinicians to consider patient-specific characteristics when determining the optimal anesthetic strategy for this patient population.
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Affiliation(s)
- Mudassir Farooqui
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Afshin A Divani
- Neurology, University of New Mexico Health System, Albuquerque, New Mexico, USA
| | | | - Marc Ribo
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
- Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Nils H Petersen
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael G Abraham
- Neurology and Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Amer Malik
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Health Care, Camden, New Jersey, USA
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sunil A Sheth
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Guillermo Linares
- Neurology, School of Medicine Saint Louis University, Saint Louis, Missouri, USA
| | - Nazli Janjua
- Neurology, Pomona Valley Hospital Medical Center, Pomona, California, USA
| | - Darko Quispe-Orozco
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Wondwossen G Tekle
- Department of Neurology, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Sara Y Sabbagh
- Neurology, University of New Mexico Health System, Albuquerque, New Mexico, USA
| | - Syed F Zaidi
- Neurology, University of Toledo Health Science Campus, Toledo, Ohio, USA
| | | | - Ayush Prasad
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Abid Qureshi
- Neurology and Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | | | | | | | - Weston Gordon
- Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Aaron Rodriguez-Calienes
- The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Cientifica del Sur Facultad de Ciencias de la Salud, Lima, Peru
| | - Juan Vivanco-Suarez
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Dileep R Yavagal
- Neurology and Neurosurgery, University of Miami, Miami, Florida, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Santiago Ortega-Gutierrez
- Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Macdonald IR, Linehan V, Sneek B, Volders D. Standardized approach to direct first pass aspiration technique for endovascular thrombectomy: Description and initial experience with CANADAPT. Interv Neuroradiol 2024:15910199241230360. [PMID: 38332478 DOI: 10.1177/15910199241230360] [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: 02/10/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is standard of care for acute ischemic stroke. Stent assisted EVT with aspiration (SOLUMBRA) technique has remained a mainstay approach. There is growing evidence that A Direct Aspiration First Pass Technique (ADAPT) is a safe, efficient and effective approach for EVT, offering several advantages. This study describes and reports initial institutional experience in the use of a standardized scientific based aspiration only technique: CANADAPT. METHODS Single center prospective cohort study was performed on consecutive patients treated for large/medium vessel ischemic stroke with CANADAPT. Intravenous thrombolytics were administered according to routine practice, independent of the decision to proceed with EVT. A sequential stepwise aspiration only technique was then applied, CANADAPT, consisting of three maneuvers, A, B and C. The reperfusion success rate, number of passes, use of rescue technique, complication rate and procedural cost were determined. RESULTS Twenty-two patients were included in this case series representing M1 (17, 77%), M1/2 (2, 9%), carotid-T (2, 9%) and basilar (1, 5%) occlusions. First pass recanalization was achieved in 11 (50%) of patients. A further four patients had successful reperfusion with a second pass of CANADAPT (total 68% success rate). Only one patient had successful reperfusion with the aspiration catheter at the clot interface (CANADAPT A). All others required some withdrawal of the aspiration catheter for reperfusion (CANADAPT B and C). Seven patients had SOLUMBRA rescue. Of these, five patients (22% of total patients) had further successful reperfusion. Overall median procedural time was 23 min for first recanalization and 30 min for final recanalization. The cost per procedure was $6630 ± 1069 for CANADAPT, and $13,530 ± 2706 for SOLUMBRA techniques. CONCLUSIONS CANADAPT represents a standardized scientific-based approach to aspiration only thrombectomy intervention. This initial study demonstrates the safety, efficiency and efficacy of this technique for use in EVT.
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Affiliation(s)
- I R Macdonald
- Division of Neuroradiology, Department of Radiology, Dalhousie University, Halifax, Canada
| | - V Linehan
- Division of Neuroradiology, Department of Radiology, Dalhousie University, Halifax, Canada
| | - B Sneek
- Penumbra Inc., Markham, ON, Canada
| | - David Volders
- Division of Neuroradiology, Department of Radiology, Dalhousie University, Halifax, Canada
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