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

• Type of Material: Article
• Authors: Raul Nogueira, Emory University; Mahmoud Mohammaden, Emory University; Tim Moran, Emory University; Matthew Whalin, Emory University; Raphael Gershon, Emory University; Alhamza Al-Bayati R R, Emory University; Jonathan Ratcliff, Emory University; Leonardo Pisani, Emory University; Bernardo Liberato, Emory University; Nirav Bhatt, Emory University; Michael Frankel, Emory University; Diogo Haussen, Emory University
• Language: English
• Date: 2021-12-01
• Publisher: BMJ PUBLISHING GROUP
• Publication Version: Final Published Version
• Copyright Statement: © Author(s) (or their employer(s)) 2021
• Final Published Version (URL): http://dx.doi.org/10.1136/neurintsurg-2020-016732
• Title of Journal or Parent Work: JOURNAL OF NEUROINTERVENTIONAL SURGERY
• Volume: 13
• Issue: 12
• Start Page: 1088
• End Page: 1094
• Grant/Funding Information: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
• Keywords: NEUROSCIENCE; CONSENSUS STATEMENT; stroke; CONSCIOUS SEDATION; MANAGEMENT; DELIRIUM; ACUTE ISCHEMIC-STROKE; ASSOCIATION; thrombectomy; SOCIETY; GENERAL-ANESTHESIA; Surgery; Life Sciences & Biomedicine; Science & Technology; ENDOVASCULAR TREATMENT; Neurosciences & Neurology; Neuroimaging
• Research Categories: Biology, Neuroscience; Health Sciences, General

Abstract

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.