Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2018.06.003
Brazilian Journal of Anesthesiology
Review Article

Anesthetic management of endovascular treatment for acute ischemic stroke: Influences on outcome and complications

Manejo anestésico do tratamento endovascular para acidente vascular cerebral isquêmico agudo: influências no resultado e complicações

Catarina Sousa Laranjo Tinoco; Patrícia Marlene Carvalho dos Santos

http://dx.doi.org/10.1016/j.bjane.2018.06.003 Braz J Anesthesiol, vol.68, n6, p.613-623, 2018
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Abstract

Abstract Background and objectives: The emerging use of endovascular therapies for acute ischemic stroke, like intra-arterial thrombectomy, compels a better understanding of the anesthetic management required and its impact in global outcomes. This article reviews the available data on the anesthetic management of endovascular treatment, comparing general anesthesia with conscious sedation, the most used modalities, in terms of anesthetic induction and procedure duration, patient mobility, occlusion location, hemodynamic parameters, outcome and safety; it also focuses on the state-of-the-art on physiologic and pharmacologic neuroprotection. Contents: Most of the evidence on this topic is retrospective and contradictory, with only three small randomized studies to date. Conscious sedation was frequently associated with better outcomes, but the prospective evidence declared that it has no advantage over general anesthesia concerning that issue. Conscious sedation is at least as safe as general anesthesia for the endovascular treatment of acute ischemic stroke, with equivalent mortality and fewer complications like pneumonia, hypotension or extubation difficulties. It has, however, a higher frequency of patient agitation and movement, which is the main cause for conversion to general anesthesia. Conclusions: General anesthesia and conscious sedation are both safe alternatives for anesthetic management of patients submitted to endovascular thrombectomy. No anesthetic management is universally recommended and hopefully the ongoing randomized clinical trials will shed some light on the best approach; meanwhile, the choice of anesthesia should be based on the patient's individual characteristics. Regarding neuroprotection, hemodynamic stability is currently the most important strategy, as no pharmacological method has been proven effective in humans.

Keywords

Anesthesia, General anesthesia, Conscious sedation, Stroke, Thrombectomy, Endovascular procedures, Neuroprotection

Resumo

Resumo Justificativa e objetivos: O uso emergente de terapias endovasculares para acidente vascular cerebral isquêmico agudo, como a trombectomia intra-arterial, nos obriga a uma compreensão melhor do manejo anestésico necessário e seu impacto nos resultados globais. Este artigo revisa os dados disponíveis sobre o manejo anestésico do tratamento endovascular, comparando anestesia geral com sedação consciente, as modalidades mais utilizadas, quanto à indução anestésica e duração do procedimento, mobilidade do paciente, localização da oclusão, parâmetros hemodinâmicos, desfecho e segurança; abordando também o estado da arte da neuroproteção fisiológica e farmacológica. Conteúdo: A maioria das evidências sobre esse tópico é retrospectiva e contraditória, com apenas três pequenos estudos randômicos realizados até o momento. A sedação consciente foi frequentemente associada a melhores resultados, mas as evidências prospectivas indicaram que não há vantagem sobre a anestesia geral em relação a essa questão. A sedação consciente é no mínimo tão segura como a anestesia geral para o tratamento endovascular do AVC isquêmico agudo, com mortalidade equivalente e menos complicações, como pneumonia, hipotensão ou extubações difíceis. Porém, a sedação consciente apresenta uma frequência maior de agitação e movimento do paciente, sendo a principal causa de conversão para a anestesia geral. Conclusões: Anestesia geral e sedação consciente são alternativas seguras para o manejo anestésico de pacientes submetidos à trombectomia endovascular. Não há um manejo anestésico que seja universalmente recomendado e esperamos que os ensaios clínicos randomizados em andamento possam lançar alguma luz sobre a melhor abordagem; enquanto isso, a escolha da anestesia deve basear-se nas características individuais do paciente. Em relação à neuroproteção, a estabilidade hemodinâmica é atualmente a estratégia mais importante, uma vez que nenhum método farmacológico se mostrou eficaz em humanos.

Palavras-chave

Anestesia, Anestesia geral, Sedação consciente, Acidente vascular cerebral, Trombectomia, Procedimentos endovasculares, Neuroproteção

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