What Anaesthesia Works Best During Endovascular Therapy for Stroke?

In carefully selected patients, minimally invasive surgery is enabling physicians to stop strokes in their tracks. As more patients undergo such procedures, physicians are debating the best way to anesthetise them. Should patients be put under general anaesthesia or should they undergo conscious sedation?

In the September, 2015 issue of the Journal of Stroke and Cerebrovascular Diseases, W. Scott Jellish, MD, and Steven B. Edelstein, MD, Loyola University Medical Center, Maywood, Illinois, detail the pros and cons of general anaesthesia and conscious sedation.

They noted that regardless of which approach is used, an anaesthesiologist or anaesthesia care team should be present to provide sedation, deep sedation or general anaesthesia.

The neuro-interventionalist is fully focused on the procedure and in many instances, not adequately directing the conscious sedation.

“The anaesthesia team is better equipped to handle procedural complications, haemodynamic control and airway emergencies that could occur during these endovascular procedures in critically ill patients,” the authors wrote.

About 85% of strokes are ischemic, and although tPA can restore blood flow, it does not always work. In such cases, endovascular therapy can be used.

The case for sedation: Several retrospective studies have found that outcomes, including in-hospital mortality and pneumonia, appear better with sedation than with general anaesthesia. Under conscious sedation, there is greater stability of blood pressure and blood flow. At a time when every minute counts, a delay may occur while waiting for an anaesthesia care team to be put in place. After an ischemic stroke, about 2 million nerve cells die every t10 minutes until blood flow is restored. Because the patient is conscious, it is possible to monitor the patient’s neurologic status during the procedure, and make adjustments if necessary.

The case for general anaesthesia: The patient is completely immobilised. Immobility is extremely important when using small catheters in very complex locations such as the brainstem, the authors noted. The inhaled anaesthetic drugs used in general anaesthesia may provide neuro-protective effects. The inhaled drugs also can be used to control blood pressure. General anaesthesia provides the ability to have a secured airway and to control carbon dioxide levels in the blood.