Mechanical thrombectomy anesthesia
The anesthesia and critical care provider may become involved for airway management due to worsening neurologic status or to enable computerized tomography (CT) or magnetic resonance imaging (MRI) scanning, to facilitate mechanical thrombectomy, or to manage critical care of stroke patients. Existing data are unclear whether the mechanical thrombectomy procedure is best performed under general anesthesia or sedation.
Non-GA during MT for anterior acute ischaemic stroke with current-generation stent retriever/aspiration devices is associated with better 3-month functional outcome and lower mortality rates. These unadjusted estimates are subject to biases and should be interpreted with caution. 1).
The Anesthesia During Stroke (AnStroke) trial randomised patients to GA (propofol/remifentanil for induction with sevoflurane/remifentanil maintenance) or CS (remifentanil infusion) with strict haemodynamic control, normal ventilation and normoglycaemia. There were no differences in early neurological recovery, infarct volume, or anaesthetic or neurointerventional complications 2).
Retrospective cohort trials favor sedation over general anesthesia, but recent randomized controlled trials (RCT) neither suggest superiority nor inferiority of sedation over general anesthesia. Regardless of anesthesia type, a critical element of intraprocedural stroke care is tight blood pressure management 3).
Systematic Review and Meta-Analysis
In a Systematic Review and Meta-Analysis, the use of either GA or CS during EMT for patients with anterior circulation acute ELVO does not yield significantly different rates of functional independence at 3 months 4).
There were no significant differences in death, symptomatic intracranial hemorrhage, anesthesiologic complication, intensive care unit length of stay, pneumonia, and interventional complication. Conclusions Moderate-quality evidence suggests that general anesthesia results in significantly higher rates of functional independence than conscious sedation in patients with ischemic stroke undergoing endovascular therapy. Large randomized clinical trials are required to confirm the benefit.
Randomized controlled trials
In a randomized controlled trial general anesthesia does not result in worse tissue outcomes or worse clinical outcomes when compared with conscious sedation in acute stroke patients with large vessel occlusion undergoing mechanical thrombectomy 5).