Analysis of the experience of anesthetic management during endovascular mechanical thrombectomy in ischemic cerebral stroke
Objective ‒ to analyze our own experience of anesthetic management during mechanical thrombectomy (MTE) in patients with acute ischemic stroke (AIS) caused by large cerebral vessels occlusion.
Materials and methods. Treatment of patients with AIS caused by large cerebral vessels occlusion was carried out in accordance with the recommendations of the European Stroke Organization (ESO). MTE was performed in 63 patients (23 women and 40 men aged 36 to 82 years, mean age ‒ 62.00 ± 16.31 years). The severity of neurological symptoms in the acute period of ischemic stroke was assessed over time using the National Institutes of Health Stroke Scale (NIHSS). The degree of disability due to stroke was assessed using a modified Rankine scale (mSR) before discharge and after 90 days. The results by mRS after 90 days were the most indicative. Early ischemic changes in the brain on computed tomograms were assessed using the Alberta Stroke Program Early CT score (ASPECTS). To reduce the time «onset-to groin time» (puncture of the femoral artery), all patients were immediately sent to the operating room upon hospitalization after neuroimaging. For MTE in 50 (79 %) cases conscious sedation with local anesthesia (sibazon, fentanyl) was used, in 13 (21%) cases ‒ general anesthesia (propofol, fentanyl, atracurium besylate). Regardless of the anesthesia method, vital signs were monitored and postoperative complications were assessed. The assessment of other important indicators related to the expiration of anesthesia was carried out: the time «onset-the the groin time» the time «from groin – to recanalization», the level of saturation, the stability of mean arterial pressure, the use of vasopressors or labetolol, the number of postoperative complications (pneumonia, dislocation with decompression craniotomy, nausea, myocardial infarction).
Results. The algorithm for anesthetic management of the perioperative period included the anesthesia during MTE, postoperative anesthetic monitoring and correction of deviations over the next 72 hours. Mandatory components of anesthetic support of MTE were to maintain blood pressure of at least 140/90 mm Hg. before reperfusion and FiO2 0.45‒0.5%. Anesthetic management also included infusion therapy, prevention of vomiting and regurgitation, and symptomatic therapy. Special attention was paid to the control of hemodynamics in the postoperative period. The results of treatment according to mRS after 90 days showed that more than half of the patients ‒ 32 (50.8%) after MTE were independent of outside help (0‒2 points), 24 (38.1 %) ‒ 3‒5 points, 6 points (mortality) ‒ 7 (11.1 %). After general anesthesia during MTE, 2 (15.4 %) deaths were registered, after MTE with conscious sedation using ‒ 5 (10.0%). There more patients with the vasopressors or labetalol using and the number of postoperative pneumonia were identified in the group with general anesthesia. For other indicators, there was no statistically significant difference in the results depending on the type of anesthesia. There was no statistically significant difference in the results in depending on anesthesia method.
Conclusions. The choice of the anesthesia method during MTE for large cerebral vessels should be individual. There was no statistically significant difference in the results in treatment of patients with AIS using MTE (in particular, in mortality), depending on the type of anesthetic management. It is also wasn’t found in the time «onset – to groin time» and the time «groin – to recanalization» with various methods of anesthesia. Indications of vital functions, saturation, mean arterial pressure in patients did not have a significant difference. Differences were revealed in terms of the vasopressors or labetolol using and the number of postoperative pneumonia, depending on the anesthesia type. The anesthesia team should be involved in patient management from the moment of hospitalization, regardless of the method of anesthesia. The results of AIS treatment depend on the initial NIHSS and ASPECTS scores, comorbidity, collateral development, perioperative complications, and the degree of reperfusion after surgery. Special attention should be paid to hemodynamics before and after reperfusion recovery after vessel recanalization, taking into account the degree of reperfusion. The influence of the type of anesthesia on the results of the treatment of AIS with the MTE using remains under the further discussion.
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