Acute Stroke Treatment: Mechanical Thrombectomy

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2 Acute Stroke Treatment: Mechanical Thrombectomy Rudy Noppens Department of Anesthesiology & Perioperative Medicine

3 CFPC CoI Templates: Slide 1 used in Faculty presentation only. Faculty/Presenter Disclosure Faculty: Dr. Ruediger Noppens, MD, PhD, FRCPC Relationships with financial sponsors: Grants/Research Support: none. Speakers Bureau/Honoraria: none. Consulting Fees: none. Patents: none. Other: Employee of London Health Sciences Center, Western University

4 CFPC CoI Templates: Slide 2 Disclosure of Financial Support This program has received financial support from CAS in the form of research grants. Potential for conflict(s) of interest: Dr. Ruediger Noppens has not received any payment/funding, etc. No organization developed/licenses/distributes/benefits from the sale of, etc. a product that will be discussed in this program

5 Code Stroke

6 Case: 68-year-old woman awoke from nap, difficulty getting up, kept falling back onto her left side. Weakness of her left arm, hand, and foot. Husband also noticed a left-sided facial droop and slurred speech. Rushed to hospital: CT / CT angio

7 Acute Stroke Cases for EVT at LHSC, London, ON 150 Stroke EVT cases Year

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10 Time Window for EVT

11 What is the current time limit for interventional therapy? A.) 4 hrs B.) 6 hrs C.) 8 hrs D.) > 12 hrs

12 Time-window for endovascular treatment Meta-analysis of pooled individual patient data 1287 adults in 5 randomized trials Thrombectomy up to 7.3 hours after symptom onset: improved outcome functional improvement: 64% (3 hrs) vs 46% (8 hours)

13 Time-window for endovascular treatment RCT: 206 patients - clinical deficit disproportionately severe to CT scan thrombectomy + standard medical care vs standard medical care alone

14 Time-window for endovascular treatment 0 [death] to 10 [no symptoms or disability]) Time window for EVT and standard medical treatment: up to 24 hours in patients with mismatch clinical presentation / CT scan

15 Presence of Anaesthesiologist

16 QI project: Anaesthesia - EVT Stroke 150 EVT Stroke Anaesthesia present Total Number %

17 Code Stroke Checklist Call RT / AA

18 QI project: Anaesthesia for EVT Stroke 50 EVT Stroke Anaesthesia present Total Number

19 rtpa (Alteplase)

20 What is not a common complications after IV rtpa administration? A.) Intracerebral hemorrhage B.) Bleeding - small lesions C.) Hypotension D.) Angioedema

21 rtpa: side effects Intracranial hemorrhage: 5.8 % Orolingual angioedema: % Risk factors: ACE inhibitor Ischemia: insula / anterior frontal cortex Anaphylactoid-like response No nasal airway! No naso-gastric tube! Foster-Goldman A, McCarthy D. Am J Ther. 2013; 20:691-3

22 General Anaesthesia vs Sedation

23 When would you prefer general anesthesia over sedation? A.) Agitated patient B.) Stroke: anterior circulation C.) Stroke: posterior circulation D.) Always sedation (associated with better outcome)

24 GA vs. Sedation General Anesthesia PRO Immobilization Improved quality of imaging Fewer complications? Airway secured Reduced risk of aspiration Lower exposure to X-ray? CON Hemodynamics: risk of hypotension Ventilation: risk of hyperventilation Time to EVT: risk of delay More resources / expertise Conscious Sedation PRO Hemodynamics: more robust Neurological monitoring Time to EVT: shorter CON Uncontrolled airway Patient movements (risk of EVT complications) EVT procedure time prolonged Higher exposure to X-ray?

25 General Anesthesia / Sedation GA (23 %) CS (77 %)

26 Patient access is limited Conversion CS to GA can be challenging!

27 GA vs. Sedation randomly assigned: general anesthesia (n = 65) vs. sedation (n = 63) infarct growth: MRI scans before EVT and hours after EVT JAMA Neurol. 2018: 75:

28 GA vs. Sedation GA did not result in worse tissue outcomes compared with CS better clinical outcomes in the GA group JAMA Neurol. 2018: 75:

29 Anesthesia technique Individualized based on clinical characteristics of each patient GA : airway protection, stroke posterior circulation, depressed level of consciousness, respiratory compromise Sedation: stroke anterior circulation, sufficient gas exchange, cooperation Anesthesia-related procedures: as quickly as possible - avoid delays Talke PO et al. J Neurosurg Anesthesiol 2014;26:95 108

30 Blood pressure control

31 Patient just arrived from Emerg, rtpa is running. What syst BP do you aim for? A.) mmhg B.) mmhg C.) mmhg D.) mmhg

32 BP: impact on neurology and stroke volume Stroke. 2004;35:

33 Blood pressure control Before revascularization: Systolic blood pressure should be maintained >140mm Hg and <180mm Hg Vasopressor choice should be based on individual patient characteristics Talke PO et al. J Neurosurg Anesthesiol 2014;26:95 108

34 Oxygen

35 Oxygen: friend or foe? Vincent JL, Taccone FS, He X: Can Respir J. 2017;2017:

36 Oxygenation / Ventilation Oxygen administration during moderate and deep sedation FiO 2 to maintain SpO 2 > 92% and PaO 2 > 60 mm Hg Ventilation: Normocapnia (PaCO 2, 35 to 45 mmhg) Talke PO et al. J Neurosurg Anesthesiol 2014;26:95 108

37 Checklist Code Stroke

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39 Suggested literature

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