You are here

  • Home
  • Online First
  • Anesthetic management for large vessel occlusion acute ischemic stroke with tandem lesions

Article Text

Article menu
Download PDFPDF
Ischemic stroke
Original research
Anesthetic management for large vessel occlusion acute ischemic stroke with tandem lesions
  1. Mudassir Farooqui1,
  2. Milagros Galecio-Castillo1,
  3. Ameer E Hassan2,
  4. Afshin A Divani3,
  5. Mouhammad Jumaa4,
  6. Marc Ribo5,6,
  7. Nils H Petersen7,
  8. Michael G Abraham8,
  9. Johanna T Fifi9,
  10. Waldo R Guerrero10,
  11. Amer Malik11,
  12. James E Siegler12,
  13. Thanh N Nguyen13,
  14. Sunil A Sheth14,
  15. Albert J Yoo15,
  16. Guillermo Linares16,
  17. Nazli Janjua17,
  18. Darko Quispe-Orozco1,
  19. Wondwossen G Tekle18,
  20. Sara Y Sabbagh3,
  21. Syed F Zaidi19,
  22. Marta Olive Gadea20,
  23. Ayush Prasad21,
  24. Abid Qureshi8,
  25. Reade Andrew De Leacy9,
  26. Mohamad Abdalkader22,
  27. Sergio Salazar-Marioni23,
  28. Jazba Soomro24,
  29. Weston Gordon25,
  30. Charoskhon Turabova17,
  31. Aaron Rodriguez-Calienes26,27,
  32. Juan Vivanco-Suarez1,
  33. Maxim Mokin28,
  34. Dileep R Yavagal29,
  35. Tudor G Jovin30,
  36. Santiago Ortega-Gutierrez31
  1. 1Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  2. 2Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
  3. 3Neurology, University of New Mexico Health System, Albuquerque, New Mexico, USA
  4. 4Neurology, Promedica Toledo Hospital, Toledo, Ohio, USA
  5. 5Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
  6. 6Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
  7. 7Neurology, Yale School of Medicine, New Haven, Connecticut, USA
  8. 8Neurology and Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
  9. 9Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  10. 10Neurosurgery, University of South Florida, Tampa, Florida, USA
  11. 11Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
  12. 12Cooper Neurological Institute, Cooper University Health Care, Camden, New Jersey, USA
  13. 13Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
  14. 14Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
  15. 15Neurointervention, Texas Stroke Institute, Plano, Texas, USA
  16. 16Neurology, School of Medicine Saint Louis University, Saint Louis, Missouri, USA
  17. 17Neurology, Pomona Valley Hospital Medical Center, Pomona, California, USA
  18. 18Department of Neurology, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
  19. 19Neurology, University of Toledo Health Science Campus, Toledo, Ohio, USA
  20. 20Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
  21. 21Yale University School of Medicine, New Haven, Connecticut, USA
  22. 22Radiology, Boston Medical Center, Boston, Massachusetts, USA
  23. 23Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
  24. 24Texas Stroke Institute, Plano, Texas, USA
  25. 25Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
  26. 26The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  27. 27Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Cientifica del Sur Facultad de Ciencias de la Salud, Lima, Peru
  28. 28Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
  29. 29Neurology and Neurosurgery, University of Miami, Miami, Florida, USA
  30. 30Neurology, Cooper University Hospital, Camden, New Jersey, USA
  31. 31Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  1. Correspondence to Dr Santiago Ortega-Gutierrez, Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City IA 52242, Iowa, USA; santy-ortega{at}uiowa.edu

Abstract

Background Endovascular therapy (EVT) stands as an established and effective intervention for acute ischemic stroke in patients harboring tandem lesions (TLs). However, the optimal anesthetic strategy for EVT in TL patients remains unclear. This study aims to evaluate the impact of distinct anesthetic techniques on outcomes in acute ischemic stroke patients presenting with TLs.

Methods Patient-level data, encompassing cases from 16 diverse centers, were aggregated for individuals with anterior circulation TLs treated between January 2015 and December 2020. A stratification based on anesthetic technique was conducted to distinguish between general anesthesia (GA) and procedural sedation (PS). Multivariable logistic regression models were built to discern the association between anesthetic approach and outcomes, including the favorable functional outcome defined as 90-day modified Rankin Score (mRS) of 0–2, ordinal shift in mRS, symptomatic intracranial hemorrhage (sICH), any hemorrhage, successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b), excellent recanalization (mTICI 3), first pass effect (FPE), early neurological improvement (ENI), door-to-groin and recanalization times, intrahospital mortality, and 90-day mortality.

Results Among 691 patients from 16 centers, 595 patients (GA 38.7%, PS 61.3%) were included in the final analysis. There were no significant differences noted in the door-to-groin time (80 (46–117.5) mins vs 54 (21–100), P=0.607) and groin to recanalization time (59 (39.5–85.5) mins vs 54 (38–81), P=0.836) among the groups. The odds of a favorable functional outcome (36.6% vs 52.6%; adjusted OR (aOR) 0.56, 95% CI 0.38 to 0.84, P=0.005) and a favorable shift in the 90-day mRS (aOR 0.71, 95% CI 0.51 to 0.99, P=0.041) were lower in the GA group. No differences were noted for sICH (3.9% vs 4.7%, P=0.38), successful recanalization (89.1% vs 86.5%, P=0.13), excellent recanalization (48.5% vs 50.3%, P=0.462), FPE (53.6% vs 63.4%, P=0.05), ENI (38.9% vs 38.8%, P=0.138), and 90-day mortality (20.3% vs 16.3%, P=0.525). An interaction was noted for favorable functional outcome between the type of anesthesia and the baseline Alberta Stroke Program Early CT Score (ASPECTS) (P=0.033), degree of internal carotid artery (ICA) stenosis (P<0.001), and ICA stenting (P<0.001), and intraparenchymal hematoma between the type of anesthesia and intravenous thrombolysis (P=0.019). In a subgroup analysis, PS showed better functional outcomes in patients with age ≤70 years, National Institutes of Health Stroke Scale (NIHSS) score <15, and acute ICA stenting.

Conclusions Our findings suggest that the preference for PS not only aligns with comparable procedural safety but is also associated with superior functional outcomes. These results prompt a re-evaluation of current anesthesia practices in EVT, urging clinicians to consider patient-specific characteristics when determining the optimal anesthetic strategy for this patient population.

  • Stroke
  • Cervical
  • Thrombectomy
  • Pharmacology
  • Intervention

Data availability statement

Data are available upon reasonable request. Data will be made available upon reasonable request to the corresponding author.

https://doi.org/10.1136/jnis-2023-021360

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Data availability statement

    Data are available upon reasonable request. Data will be made available upon reasonable request to the corresponding author.

    View Full Text

    Footnotes

    • Twitter @mili_galecio, @marcriboj, @Michael3Abraham, @WaldoGuerrero82, @AmerMalikMD, @JimSiegler, @NguyenThanhMD, @AlbertJYoo, @rdeleacymd, @AaronCalienes, @jsvivanco1, @CerebrovascLab

    • MF and MG-C contributed equally.

    • Collaborators N/A.

    • Contributors Contributorship statement: SOG, MF, MGC, AEH, AAD, MAJ, MR, NHP, MGA, JTF, WRG, AM, JES, TNN, SAS, AJY, GL, NJ, MM, DTY, and TGJ designed the study and revised the manuscript. MF, DQO, MGC, WGT, SYS, SFZ, MOG, AP, AQ, RADL, MA, SSM, JS, WG, CT, ARC, and JVS collected the data. SOG and MGC wrote the statistical analysis plan. DQP and MGC cleaned and analyzed the data. SOG, MF, and MGC drafted and revised the manuscript. Guarantor: SOG. All the authors revised and approved the final version of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests SOG: research support from the NIH-NINDS (R01NS127114-01, RO3NS126804-01), Stryker (N/A), Medtronic(N/A), Microvention(N/A), Methinks(N/A), IschemiaView(N/A), Viz.ai(N/A), and Siemens(N/A); and consulting fees from Medtronic and Stryker Neurovascular. TN: advisory board for Idorsia, Brainomix. NP: research support from the NIH/NINDS (K23NS110980) and Liminal Sciences (N/A). TGJ: advisor and investor for Anaconda, Route92, Viz.AI, FreeOx, Blockade Medical, and Methinks; grant support from Medtronic (N/A) and from Stryker Neurovascular (N/A) in his capacity as principal investigator for DAWN and AURORA; he received personal fees in his role on the Data Safety Monitoring Board. The other co-authors do not report conflicts of interests.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.