Anaesthetic Management of Patient with Acute Stroke.pptx

Anaesthetic Management of Acute Stroke

1. ANAESTHETIC MANAGEMENT OF PATIENT WITH ACUTE ISCHEMIC STROKE Presenter : Dr Kam Yih Chun, Dr Tan Kai Lun Supervisor: Dr Looi JK

2. iNTRODUCTION Stroke remains the second-leading cause of death and the third-leading cause of death and disability combined (as expressed by disability-adjusted life-years lost – DALYs) in the world . (Valerie L Feigin et al./WSO: Global Stroke Fact Sheet 2022) In 2020, there were 7.08 million deaths attributable to cerebrovascular disease worldwide (3.48 million deaths from ischemic stroke , 3.25 million deaths from intracerebral hemorrhage (ICH), and 0.35 million from subarachnoid hemorrhage) ( Tsao CW et al (2022) Heart Disease & Stroke Statistical Update Fact Sheet Global Burden of Disease)

3. Introduction Cerebrovascular disease is the 4 th most common cause of death in Malaysia in 2021 ( Department of Statistics of Malaysia 2022 ) Mortality rate for cerebrovascular disease is 6.5 % In 2019, data from Malaysia showed a rising trend with incidence 47, 911 (UI 43,757–52,839); deaths 19,928 (95% UI: 15,909–25,000); prevalence 443,995 (95% UI: 414,703–476,838 ); DALYS 512,726 (95% UI: 420,450–629,695) ( Kaysin Tan et al 2022 Stroke burden in Malaysia) Ischaemic stroke accounted for 79.4% of all stroke cases, followed by haemorrhagic stroke (18.2%), transient ischaemic attack (2%) and unclassified stroke (0.4%). ( CPG Malaysia of Ischemic stroke 2020)

4. CAUSEs OF ACUTE ISHEMIC STROKE

5. Time is brain The target of therapy is the ischaemic penumbra- threatened but salvageable tissue surrounding the infarct core The ischaemic penumbra is short-lived, lasting only for a few hours in human patients. The typical ischaemic stroke patient loses 1.9 million neurones for each minute they are untreated. Compared with the normal rate of neuron loss in brain ageing, the ischaemic brain ages 3.6 yr each hour without treatment ( Jauch EC, Saver JL, Adams HP Jr, et al. 2013)

6. NIH EMERGENCY RESPONSE TIME FOR AIS

7. treatment Method of reperfusion:- Medical therapy . I.V. thrombolysis with recombinant tissue plasminogen activator ( rtPA ) Surgical therapy Mechanical thrombectomy (MT) Intracranial stenting Microsurgical intervention (MSI) Microsurgical embolectomy (MSE) Extracranial-intracranial (EC-IC) bypass

8. Iv thrombolysis Indicated for patients with onset of symptoms within 4.5 hours of presentation with no contraindication to rTPA Thrombolysis has better outcomes achieved with earlier administration. (Jauch EC et al 2013 ) US population thrombolysis rate: 3–8.5% (Reeves MJ, Arora S et al 2006) Malaysia population thrombolysis rate: 0.65% (Aziz ZA et al 2016)

9. MECHANICAL/ENDOVASCULAR THOMBECTOMY (EVT) EVT for large vessel occlusion (LVO) is indicated in acute ischemic stroke that presents within 6-8 hours to 24 hours using advanced imaging such as CT/MR perfusion scan. LVO Internal carotid artery (ICA) M1 Middle cerebral artery (MCA)occlusions It is reasonable to include EVT for ACA, PCA and basilar artery occlusions. However, recanalization is still not reached in 11–29% of patients, with a final thrombolysis in cerebral infarction (TICI) score of 0–1 after MT (Leishner H et al 2019)

10. Mechanical/endovascular thombectomy (EVT) CT Scan criteria

11. Microsurgical intervention Two main approach:- Microsurgical embolectomy (MSE) – Direct vessel recanalization Extracranial-intracranial (EC-IC) bypass

12. MICROSURGICAL EMBOLIZATION ( mse ) Physically remove the embolus from Advantage of MSE lies in its potential for recanalizing the perforators in cases where they branch from the occluded segment, with the sphenoidal part of the middle cerebral artery (MCA) The first MSE was performed by Jacobson and Donaghy in 1962. In small samples of patients treated with MSE only, the recanalization rate reached 91–100% (Hino A, Oka H, Hashimoto Y, et al 2016)

13. EXTRACRANIAL INTRACRANIAL (EC-IC) BYPASS first performed by Woringer and Kunlin in the case of an internal carotid artery (ICA) occlusion in 1962 and then by Yaşargil in the case of MCA occlusion in 1967 ( Yaşargil MG. 2010) The superficial temporal artery (STA) acts as a donor providing blood flow to the MCA trunks or segments distal to the occlusion site, with the cause of the blockage left in situ Potentially suitable for cases of intracranial atherosclerosis where MSE failure is expected ( Kanematsu R, Kimura T, Ichikawa Y, et al 2018)

14. Criteria for microsurgical

15. CHOICE OF ANESTHETIC TECHNIQUE: GA VS MAC Z.H Anastasian 2014

16. CHOICE OF ANESTHETIC TECHNIQUE Retrospective analyses of very large numbers of patients support MAC, Most non randomized studies are limited by potential selection bias , as choice of anesthetic technique was at discretion of anesthesiologist or interventionalist with higher NIHSS score in patient receiving GA well-done single-center randomized controlled trials with much smaller numbers show no difference or modestly improved outcomes with GA The best available evidence suggest that GA with optimal hemodynamic control may improve technical success (Maurice A, Eugène F et al 2022) and functional outcome (Campbell D, Butler E, et al 2023)

17. Seven RCTs were included in the systematic review and meta-analysis. Sample size: 980 participants A systematic search for trials in which stroke EVT patients were randomized to GA or non-GA was performed in Medline, Embase, and the Cochrane Central Register of Controlled Trials. A systematic review and meta-analysis using a random-effects model was performed. Conclusion: GA improves recanalization by 9.0%, and the proportion of patients with functional recovery improves by 8.4% There was no difference in hemorrhagic complications or 3-month mortality.

18. Patients received either a standardized GA or a standardized conscious sedation. Blood pressure control was also standardized in both groups. The primary outcome measure was a modified Rankin score less than or equal to 2 (0 = no symptoms; 5 = severe disability) assessed 3 months after treatment. Conclusion : The functional outcomes 3 months after endovascular treatment for stroke were similar with general anesthesia and sedation . Single-blind randomized trial Sample size : 351 randomized patients, 345 were included

19. CHOICE OF ANESTHETIC TECHNIQUE Issues to consider:- MAC Can lie flat Cooperative , able to communicate and able to protect airways No increased risk of respiratory depression or airway obstruction with sedation (Sleep-related respiratory dysrhythmias may be present up to 95% of stroke patient- lead to hypoxemia, vibration of radiologic view due to snoring or respiratory failure ( Bassetti C, Aldrich MS 1999) GA Poor neuroligic examination Inattention or disinhibition Hemodynamically unstable Cannot lie flat and high risk of aspiration High risk of seizure Requiring endotracheal intubation for impending respiratory failure or airway protection

20. HEMODYNAMIC MANAGEMENT Society for Neuroscience in Anesthesiology and Critical Care recommended: - systolic blood pressure should be maintained between 140 and 180 mmHg prior to recanalization, whether or not the patient receives intravenous (IV) tissue plasminogen activator (tPA), and diastolic blood pressure should be maintained <105 mmHg - Most importantly, avoid sustained hypotension and hypertension. The exact definitions of hypotension and hypertension are somewhat ill-defined. There are no reliable technologies that allow hemodynamic titration based on individualized assessment of neurophysiology. - Continuous blood pressure, heart rate, and cardiac rhythm monitoring as soon as diagnosis of AIS is confirmed.

21. Once euvolemia is achieved, vasoactive medications should be used to achieve and maintain blood pressure goals. The vasopressor of choice is usually a potent alpha-agonist, such as norepinephrine or phenylephrine , since the most likely cause of hypotension is anesthetic induced vasodilation. For control of hypertension, nicardipine , labetalol , and clevidipine are the first choice agents.

22. There are no prospective trials of blood pressure management during EVT. A secondary analysis of the General or Local Anesthesia in Intra Arterial Therapy (GOLIATH) trial, in which patients were randomly assigned to general anesthesia (GA) or conscious sedation (CS) for EVT, reported no associations between blood pressure-related variables and neurologic outcome . In contrast, a subsequent analysis of data from 365 patients who were included in the GOLIATH, Sedation Versus Intubation for Endovascular Stroke Treatment (SIESTA), and Anesthesia during stroke (AnStroke) trials found that sustained hypotension and hypertension were associated with worse neurologic outcome . Conclusion: Critical MAP thresholds and durations for poor outcome were found to be MAP less than 70 mm Hg for more than 10 minutes and MAP greater than 90 mm Hg for more than 45 minutes , both durations with a number needed to harm of 10 patients. Mean arterial blood pressure may be a modifiable therapeutic target to prevent or reduce poor functional outcome after EVT.

23. FLUID MANAGEMENT Goals for fluid management during EVT include - maintenance of normovolemia to achieve adequate cerebral perfusion, and avoidance of cerebral edema. - administered at a rate and volume that achieves even fluid balance - volume status should be assessed with dynamic tests of fluid responsiveness, such as pulse pressure variation and/or stroke volume variation.

24. GLUCOSE MANAGEMENT Blood glucose should be monitored closely in patients with AIS, as both hypoglycemia and hyperglycemia may worsen neurologic outcome. Hyperglycemia is common in patients with stroke, whether or not they have diabetes. Serum glucose >7.8mmol/L is associated with larger infarct size, inability to recanalize despite use of tissue plasminogen activator, lack of clinical improvement 24 hours after EVT, and increased risk of mortality. Emerging evidence suggests that continuous glucose monitoring may be beneficial for patients with AIS.

25. Conclusions: Persistent hyperglycemia was correlated with mortality after acute ischemic stroke.

26. Conclusions: High mean glucose levels more than 8 mmol/L of blood glucose of blood glucose during the initial 72 hours of acute stroke were associated with death or dependency at 3 months.

27. We manage blood glucose during EVT as follows: ●Measure glucose every 45 to 60 minutes during EVT. ●Low serum glucose (<3.3 mmol/L) should be corrected rapidly. It is reasonable to aim to maintain blood glucose between 7.8 mmol/L and 10 mmol/L. ●Large swings in serum glucose should be avoided. An intravenous (IV) insulin infusion should be considered for easy titration intraoperatively. Most experts recommend protocol-driven IV insulin rather than intermittent subcutaneous dosing.

28. TEMPERATURE MANAGEMENT Patient temperature should be monitored during EVT, with the goal of maintaining normothermia. Core temperature should be maintained between 35 and 37°C. Hyperthermia should be avoided, as fever has been associated with poor neurologic outcome after stroke. Patients tend to become hypothermic during anesthesia; if necessary room temperature can be increased and warming devices may be used. It is often possible to cover the patient's head with a warm blanket to reduce heat loss. Although therapeutic hypothermia may be beneficial in certain patients with neurologic injury, no evidence supports its routine use in AIS during EVT.

29. COMPLICATIONS 1) Intracranial arterial perforation Arterial perforation is likely the most feared and serious complication during EVT, and can lead to functional disability and poor long-term outcomes, especially in the setting of recent intravenous (IV) thrombolysis. Rates of perforation have been reported between 0 and 4.9 percent in clinical trials. Arterial perforation requires immediate management, in consultation with the neuro-interventionalist, as follows: ●Call for help, and for immediate neurosurgical consultation if the proceduralist is not a neurosurgeon ●Alert the operating room that emergency craniotomy may be necessary ●Control blood pressure with careful titration of short-acting medications (eg, nicardipine, nitroprusside), aiming for a systolic blood pressure ≤140 mmHg ●Discuss with the interventionalist discontinuation and immediate reversal of heparin, tPA, and any other anticoagulant or antiplatelet medications in effect. Reversal of tPA includes administration of two units of platelets, two units of fresh frozen plasma, and two units of cryoprecipitate IV, with further treatment based on patient-specific factors and laboratory values. ●Treat elevated intracranial pressure as needed.

30. 2) Extracranial arterial perforation Arterial perforation in the chest, abdomen, or retroperitoneum may occur during the procedure, and may be indicated by an unexplained decrease in blood pressure. If such a perforation is suspected, the following steps are appropriate: ●Notify the interventionalist who may be able to confirm the diagnosis angiographically. ●If the diagnosis is confirmed call for help; a vascular neurosurgeon or other interventionalist may be required. ●Increase venous access as necessary. ●Alert the operating room if an invasive procedure is contemplated. ●Control blood pressure with careful titration of short-acting medications (eg, nicardipine, nitroprusside), aiming for a systolic blood pressure ≤140 mmHg.

31. POSTPROCEDURE CARE We monitor patients continuously during transport from the interventional suite to the intensive care unit (ICU). Basic monitors should include electrocardiogram, invasive and/or noninvasive blood pressure, pulse oximetry, and if possible, respiratory rate and end-tidal carbon dioxide (ETCO2). Emergency medications and airway equipment should be immediately available. Postintervention patients, regardless of the presence or absence of invasive airway, should ideally be admitted to a dedicated ICU specialized in the care of stroke patients. Once in the ICU, the anesthesia provider must continue to monitor hemodynamics until a proper patient handoff is complete, since hemodynamic instability can occur during the ICU admission process.

32. rEFERENCES Valerie L Feigin et al. (2022) World Stroke Organization (WSO): Global Stroke Fact Sheet 2022 Jovany Cruz Navarro, MD et all 2023 UpToDate Anesthesia for endovascular therapy for acute ischemic stroke in adults Tsao CW et al (2022) Heart Disease & Stroke Statistical Update Fact Sheet Global Burden of Disease Kaysin Tan et al 2022 Stroke burden in Malaysia Aziz ZA, Lee YYL, Sidek NN, Bahari AN, Looi I, Hanip MR, et al. Gender disparities and thrombolysis use among patient with first-ever ischemic stroke in Malaysia. Neurol. Res. 2016;38:406–13 Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2013; 44: 870–947 Hino A, Oka H, Hashimoto Y, et al. Direct microsurgical embolectomy for acute occlusion ofthe internal carotid artery and middle cerebral artery. World Neurosurgery 2016;88:243–51. Bassetti C, Aldrich MS 1999 Sleep apnea in acute cerebrovascular diseases: final report on 128 patients. ;22(2):217. Douglas Campbell et al 2023 General Anesthesia Compared With Non-GA in Endovascular Thrombectomy for Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials Axelle Maurice et al 2022 Donghua Mi et al 2018 Correlation of hyperglycemia with mortality after acute ischemic stroke Shinichi Wada et al 2018 Outcome Prediction in Acute Stroke Patients by Continuous Glucose Monitoring Sleep apnea in acute cerebrovascular diseases: final report on 128 patients. AU Bassetti C, Aldrich MS  SO Sleep. 1999;22(2):217.  Sleep apnea in acute cerebrovascular diseases: final report on 128 patients. AU Bassetti C, Aldrich MS  SO Sleep. 1999;22(2):217.