Monitored anesthesia care during mechanical thrombectomy for stroke: need for data-driven and individualized decisions.

BACKGROUND: The optimal anesthesia management for patients with stroke undergoing mechanical thrombectomy (MT) during the COVID-19 pandemic has become a matter of controversy. Some recent guidelines have favored general anesthesia (GA) in patients perceived as high risk for intraprocedural conversion from sedation to GA, including those with dominant hemispheric occlusions/aphasia or baseline National Institutes of Health Stroke Scale (NIHSS) score >15. We aim to identify the rate and predictors of conversion to GA during MT in a high-volume center where monitored anesthesia care (MAC) is the default modality. METHODS: A retrospective review of a prospectively maintained MT database from January 2013 to July 2020 was undertaken. Analyses were conducted to identify the predictors of intraprocedural conversion to GA. In addition, we analyzed the GA conversion rates in subgroups of interest. RESULTS: Among 1919 MT patients, 1681 (87.6%) started treatment under MAC (median age 65 years (IQR 55-76); baseline NIHSS 16 (IQR 11-21); 48.4% women). Of the 1677 eligible patients, 26 (1.6%) converted to GA including 1.4% (22/1615) with anterior and 6.5% (4/62) with posterior circulation strokes. The only predictor of GA conversion was posterior circulation stroke (OR 4.99, 95% CI 1.67 to 14.96, P=0.004). The conversion rates were numerically higher in right than in left hemispheric occlusions (1.6% vs 1.2%; OR 1.37, 95% CI 0.59 to 3.19, P=0.47) and in milder than in more severe strokes (NIHSS ≤15 vs >15: 2% vs 1.2%; OR 0.62, 95% CI 0.28 to 1.36, P=0.23). CONCLUSIONS: Our study showed that the overall rate of conversion from MAC to GA during MT was low (1.6%) and, while higher in posterior circulation strokes, it was not predicted by either hemispheric dominance or stroke severity. Caution should be given before changing clinical practice during moments of crisis.

A Case Report Describing the Use of Point of Care Ultrasound to Guide Successful Cardiopulmonary Resuscitation After Unanticipated Arrest in Ambulatory Surgery.

We present a case of a 41-year-old man who suffered cardiac arrest after induction of general anesthesia for an ambulatory ophthalmologic procedure. In this report, we highlight the use of focused transthoracic echocardiography by the anesthesia team to guide a prolonged resuscitation. Emergency room and critical care physicians have described the use of focused echocardiography to aid in diagnosing correctible causes of cardiac arrest, predicting outcomes, and in decision making regarding termination of resuscitation. We discuss benefits and barriers to anesthesiologists incorporating focused cardiac ultrasound into the perioperative arena.

Dexmedetomidine: a safe alternative to general anesthesia for endovascular stroke treatment.

BACKGROUND AND PURPOSE: There have been reports that general anesthesia (GA) is associated with worse clinical outcomes during intra-arterial treatment (IAT) for stroke. Since traditional sedatives carry the risk of respiratory depression, this retrospective study was designed to compare sedation with the α2 adrenergic agonist dexmedetomidine (DEX) and with GA for IAT procedures. METHODS: We reviewed our institutional endovascular database of 216 consecutive patients who received DEX or GA for IAT of anterior circulation strokes between September 2010 and July 2012. The demographic, radiographic and angiographic variables between the GA and DEX groups were compared, as well as hemodynamic changes during the procedure. Binary logistic regression models were generated to determine the independent predictors of a favorable outcome (defined as a modified Rankin Score at 90 days of 0-2). RESULTS: 83 patients had IAT performed under DEX sedation. Their demographic characteristics were similar to those given GA except that they were older and had less severe strokes. The GA group experienced greater variations in blood pressure, more hypotension with induction (54% vs 28%, p<0.001) and greater use of vasopressors (79% vs 58%, p<0.001). In our regression models, independent predictors of a good outcome included age, NIH Stroke Scale (NIHSS) score, Alberta Stroke Program Early CT score (ASPECTS), successful reperfusion, lower baseline systolic blood pressure and higher blood pressures during the procedure. DEX was associated with a good outcome when models included NIHSS as the sole measure of stroke severity but was equivalent to GA when ASPECTS was added to the analysis. CONCLUSIONS: DEX can be safely administered in patients undergoing endovascular reperfusion therapies. Further study is required to determine if outcomes are different among sedatives used during such procedures.

Higher volume endovascular stroke centers have faster times to treatment, higher reperfusion rates and higher rates of good clinical outcomes.

BACKGROUND AND PURPOSE: Technological advances have helped to improve the efficiency of treating patients with large vessel occlusion in acute ischemic stroke. Unfortunately, the sequence of events prior to reperfusion may lead to significant treatment delays. This study sought to determine if high-volume (HV) centers were efficient at delivery of endovascular treatment approaches. METHODS: A retrospective review was performed of nine centers to assess a series of time points from obtaining a CT scan to the end of the endovascular procedure. Demographic, radiographic and angiographic variables were assessed by multivariate analysis to determine if HV centers were more efficient at delivery of care. RESULTS: A total of 442 consecutive patients of mean age 66 ± 14 years and median NIH Stroke Scale score of 18 were studied. HV centers were more likely to treat patients after intravenous administration of tissue plasminogen activator and those transferred from outside hospitals. After adjusting for appropriate variables, HV centers had significantly lower times from CT acquisition to groin puncture (OR 0.991, 95% CI 0.989 to 0.997, p=0.001) and total procedure times (OR 0.991, 95% CI 0.986 to 0.996, p=0.001). Additionally, patients treated at HV centers were more likely to have a good clinical outcome (OR 1.86, 95% CI 1.11 to 3.10, p<0.018) and successful reperfusion (OR 1.82, 95% CI 1.16 to 2.86, p<0.008). CONCLUSIONS: Significant delays occur in treating patients with endovascular therapy in acute ischemic stroke, offering opportunities for improvements in systems of care. Ongoing prospective clinical trials can help to assess if HV centers are achieving better clinical outcomes and higher reperfusion rates.