Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 2: Integrating and Applying Observational Reports and Randomized Clinical Trials

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.