Interventional therapies in stroke management: anaesthetic and critical care implications

Abstract

### Key points Recent advances in stroke therapy have necessitated new multidisciplinary care pathways. This article will cover interventions used in acute stroke management, including the role of imaging, thrombolysis, interventional radiology, arterial pressure (AP) management, carotid revascularization, haematoma evacuation, and decompressive hemicraniectomy (DHC). The anaesthetic and critical care implications of these interventions are described. Computed tomography (CT) scanners have increased from a single-slice detector to advanced 320-slice scanners capable of performing whole-head imaging in a single rotation. This allows multiple acquisitions during a single contrast injection such that non-contrast CT, angiogram, subtraction cerebral angiography, and perfusion imaging can be performed in a single sitting. With CT perfusion scans, the size of the infarcted core can be seen and also the hypoperfused area around it (the penumbra) which represents brain tissue that may be salvaged if blood flow is restored with reperfusion therapies. Similar advances have been made with magnetic resonance imaging (MRI). MRI with diffusion-weighted imaging (DWI) can differentiate between recent infarction, intracranial masses, and inflammatory disease, and is more sensitive than CT for the detection of acute infarction. It does however have disadvantages in that acutely ill patients may not tolerate it as well and some may even have contra-indications for MRI. Furthermore, MRI may not be readily available in the emergency setting, the acquisition time is longer and MRI is more expensive than CT. Since the primary aim of imaging in acute stroke is to exclude intracranial haemorrhage (which CT is very well suited for), …