Acute Stroke Treatment: Mechanical Thrombectomy Rudy Noppens Department of Anesthesiology & Perioperative Medicine
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
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
Code Stroke
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
Acute Stroke Cases for EVT at LHSC, London, ON 150 Stroke EVT cases 100 50 0 2014 2015 2016 2017 Year
Time Window for EVT
What is the current time limit for interventional therapy? A.) 4 hrs B.) 6 hrs C.) 8 hrs D.) > 12 hrs
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)
Time-window for endovascular treatment RCT: 206 patients - clinical deficit disproportionately severe to CT scan thrombectomy + standard medical care vs standard medical care alone
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
Presence of Anaesthesiologist
QI project: Anaesthesia - EVT Stroke 150 EVT Stroke Anaesthesia present Total Number 100 50 66 % 0 2014-2017
Code Stroke Checklist Call RT / AA
QI project: Anaesthesia for EVT Stroke 50 EVT Stroke Anaesthesia present Total Number 40 30 20 10 0 2017-2018
rtpa (Alteplase)
What is not a common complications after IV rtpa administration? A.) Intracerebral hemorrhage B.) Bleeding - small lesions C.) Hypotension D.) Angioedema
rtpa: side effects Intracranial hemorrhage: 5.8 % Orolingual angioedema: 1.9 5.1 % 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
General Anaesthesia vs Sedation
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)
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?
General Anesthesia / Sedation 2015-2018 GA (23 %) CS (77 %)
Patient access is limited Conversion CS to GA can be challenging!
GA vs. Sedation randomly assigned: general anesthesia (n = 65) vs. sedation (n = 63) infarct growth: MRI scans before EVT and 48-72 hours after EVT JAMA Neurol. 2018: 75:470-477
GA vs. Sedation GA did not result in worse tissue outcomes compared with CS better clinical outcomes in the GA group JAMA Neurol. 2018: 75:470-477
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
Blood pressure control
Patient just arrived from Emerg, rtpa is running. What syst BP do you aim for? A.) 100-120 mmhg B.) 130-140 mmhg C.) 160-180 mmhg D.) 200-220 mmhg
BP: impact on neurology and stroke volume Stroke. 2004;35:520-527
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
Oxygen
Oxygen: friend or foe? Vincent JL, Taccone FS, He X: Can Respir J. 2017;2017:2834956.
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
Checklist Code Stroke
Suggested literature http://www.snacc.org