Anaesthesia and endovascular therapy in patients with acute ischaemic stroke

Abstract

Editor, We were surprised to notice that during endovascular therapy in acute ischaemic stroke anaesthesiologists are only called in when general anaesthesia is required. We have obtained this information from several recently published surveys that indicate that often nonanaesthesiologists provide sedation during endovascular treatment of acute ischaemic stroke. A national survey on anaesthetic management during acute ischaemic stroke conducted by the Neuroscience Section of the Spanish Society of Anaesthesiology, Resuscitation and Pain Management (SEDAR) highlights that anaesthesiologists did not participate in the periprocedural care of these neurocritical patients in more than 20% of the 47 reference stroke units in Spain.1 In 16% of the centres participating in a similar survey carried out simultaneously in northern Europe, departments of Anaesthesiology were not always responsible for providing the periprocedural care.2 Another survey carried out by the members of the Interventional Neuroradiology services of 30 centres trained in the endovascular treatment of acute ischaemic stroke in the United States showed similar results.3 Anaesthesiology departments routinely participated in 67% of the procedures, and sometimes only in 7%. The clinical practice is far from the recommendations on procedural sedation and analgesia established in the recent guidelines published by the European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology.4 This task force recommends that pre-procedural evaluation and procedural management of patients classified as American Society of Anesthesiology (ASA) physical status III or IV, should only be performed by anaesthesiologists (level of evidence B; grade of recommendation strong). It is not difficult to understand that patients requiring endovascular treatment for acute ischaemic stroke are complex and critical, and enter into this ASA classification. It should be kept in mind that these patients usually have a history of decompensated cardiovascular disease and high scores in neurological grading (NIHSS stroke scale). Moreover, these guidelines provide another reason why the PSA of these patients should be performed by anaesthesiologists: patients older than 70 years are given the same considerations as patients classified as ASA III or IV with a higher level of evidence (level of evidence A; grade of recommendation strong). Epidemiological data indicate that stroke occurs mainly in the elderly population, since more than 75% of patients suffering from this disease are older than 65 years. Therefore, even these guidelines that contemplate sedation by non-anaesthesiology professionals, point out that procedural sedation and analgesia in patients with acute ischaemic stroke should be performed by anaesthesiologists. If we ignore these guidelines and assume that non-anaesthesiologists with specific skills can perform sedation during this procedure, we will have two issues to address. First of all, consider what would happen if it is necessary to convert to general anaesthesia. Neurological status of these patients makes both their collaboration level and their airway patency unpredictable during the procedure. The rate of conversion from sedation to general anaesthesia in endovascular treatment of acute ischaemic stroke has already been outlined; it is not negligible (1.7 to 14%).2,5 In addition, a recent study showed that the mortality rate of these patients was 16.3%, but increased to 50% when conversion to general anaesthesia was needed.6 The second issue is inherent complications. Iatrogenic perforation of the vessels with symptomatic haemorrhage (subarachnoid, intracerebral or intraventricular), distal embolisation, vascular dissection, vasospasm, focal and/or generalised epilepsy, vascular re-occlusion and reperfusion syndrome are very serious complications that require immediate diagnosis and treatment. The presence of an anaesthesiologist optimises the patients’ haemodynamic control and increases their safety in case these complications appear.6 As indicated therein, these the ESA guidelines on procedural sedation and analgesia4 support the different national societies of anaesthesiologist and can lay the groundwork for deciding how procedural sedation and analgesia should be carried out and by whom. The neuroscience section of SEDAR, after rigorously analysing the current quality and safety of endovascular treatment of acute ischaemic stroke,7 and relying on European guidelines for procedural sedation and analgesia,4 argues that anaesthesiologists should be involved in the endovascular treatment of acute ischaemic stroke, regardless of the type of anaesthesia. We believe that the management of these patients by anaesthesiologist professional increases the safety of the procedure and could improve the prognosis in high-risk situations. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none.