Perioperative anesthetic management can have profound effects on patient outcomes for those who are either at risk for stroke during noncardiac surgery or who have had acute ischemic stroke (AIS) and are having endovascular thrombectomy (EVT). Intraprocedural variables, such as blood pressure management, respiratory parameters, medications or time between recognition of AIS and treatment, can all be determinants of new intraprocedural stroke or EVT efficacy.
“We know anesthesia can play a role in the incidence and risks of covert stroke during the perioperative period – however, recognition of the actual mechanisms is poorly understood,” said Deborah A. Rusy, M.D., M.B.A., FASA, Professor of Anesthesiology at the University of Wisconsin and Director of Perioperative Services at American Family Children’s Hospital in Madison. “We now have randomized, controlled trials looking at the provision of conscious sedation versus general anesthesia in patients with AIS having EVT. We’re gaining a better understanding of how perioperative decision-making may influence outcomes.”
Dr. Rusy will moderate Tuesday’s session “Update on Stroke for the Anesthesiologist.” Laurel E. Moore, M.D., Associate Professor of Anesthesiology and Director of Neuroanesthesia at the University of Michigan College of Medicine, will discuss the latest findings in covert perioperative stroke. She will focus on clinical treatment decisions that may affect the incidence of perioperative stroke.
“The clinical decisions we make as anesthesiologists can have an effect in perioperative stroke,” Dr. Rusy said. “Things that we have some control over, such as holding anticoagulants and aspirin before surgery, blood pressure monitoring and control and transfusion triggers, can all play a role.”
There have been many recent developments in the treatment of AIS, including new technologies for thrombectomy treatment. These new therapies often require anesthesia for the management of airway and physiologic variables and prevention of patient movement during critical periods of the procedure
Bradley J. Hindman, M.D., Professor of Anesthesia-Neuroanesthesia at the University of Iowa Carver College of Medicine in Iowa City, will review and compare the findings of early observational studies and the latest RCT findings from Europe. He’ll compare general anesthesia versus conscious sedation in patients with acute stroke having EVT and subsequent patient outcome.
“There are critical time limitations when patients are having endovascular thrombectomy,” Dr. Rusy said. “It’s important to get these patients in and treated early and maintain systolic blood pressure for collateral perfusion, preferably between 140 and 180 mmHg. The technology that the proceduralist uses is important, too.”
Much of current anesthesia practice is based on older retrospective observational studies that compared general anesthesia with conscious sedation during thrombectomy. It is now recognized that these studies may have had selection bias. There have been a number of newer, single-center, randomized, controlled trials published in the past 18 to 24 months. Examples include GOLIATH (General or Local Anesthesia in Intra Arterial Therapy), ANSTROKE (Anesthesia During Stroke) and SIESTA (Sedation versus Intubation for Endovascular Stroke Treatment).
“Dr. Hindman will discuss the outcomes of these studies, the limitations and what future studies are needed,” Dr. Rusy said. “There is an enormous focus on stroke treatments and outcomes not just in the United States, but globally. If acute ischemic stroke can be recognized and treated quickly, many of these patients can have close to full recovery. Most of these patients will require some type of anesthesia, and our anesthetic efforts can make a significant difference in patient outcomes.”