well thank you very much doctor mayor
for this kind introduction
my only disclosure is that I even though
I'm giving a talk on anesthesia I'm a
neurologist I'm not an NCC ologist so
this topic became of extreme relevance
you know in the wake of all the new
trials the five you know the big fat or
big fat five like you call them and and
the recent you know Don trial what do we
do with a patient who presents to us
with an L vo and who needs to undergo
you know needs to go straight to angio
to undergo thrombectomy what do we what
do we use you know in terms of sedation
in order to well first of all keep the
patient safe still you know on the
engine table but also minimize the time
that you're actually getting the patient
you know sedated and achieving you know
the optimal or you know the fastest time
to grow in puncture so very classically
you get a phone call obviously at 2:00
or 3:00 a.m. of this patient who's you
know got an NIH or scale of 22 he's in
your II D and you need to activate you
know a stroke call a code or stroke
alert and so you know the resident gets
busy with calling the neuro
interventionalist was on call but also
the the neuro ICU to let them know that
there was a patient that will be coming
after angio you have you know the to
book the angio suite etc and inevitably
the question comes you know what do we
do you know to sedate the patient are
you going to intubate the patient put
them down because while it makes sense
you know the patient needs to really
remain still you know the or do you do
what we call Mac and Mac is monitored
anesthesia care also known as conscious
sedation so I'll be using the two terms
pretty interchangeably so in some cases
really it's a slam-dunk right it's the
patient is extremely agitated
you know those bad you know right
parietal strokes you know where the
patient loses you know pretty much side
of you know what's going on with them
and and really needs to be you know to
have the big guns you know used in order
to sedate them or the patient whose
aspirating because they're vomiting and
so that's a risk you know for aspiration
pneumonia or again you know the patient
who basically has lost brainstem
reflexes to the point where they're not
protecting their airway it's a slam-dunk
you're going to potentially you know
just intubate and put them under general
anesthesia but in most cases as a matter
of fact we we don't know we could go
either way really so there's really real
clinical equipoise now why is this you
know
topic such an important topic well first
of all intubation sedation you know it's
not an easy matter on the brain I bring
that suffering you know from a major
stroke has an L vo or even a smaller you
know occlusion in a more distal branch
is really relying on collateral flow and
and really drops in the blood pressure
related to sedation or the act of
intubating someone can actually be very
detrimental and expand that zone of
infarct and that penumbra that we are so
eager to restore right so the take-home
message is really from this you know
talk is that well in the past we used to
think that general anaesthesia was was
detrimental and that most actually most
institutions will try to you know if
they can if they have the capability to
go with a conscious sedation but recent
RCTs actually we only have two to date
you know weirdly enough suggests that
there's really no superiority of one
modality versus the other regarding
early neurological improvement after
thrombectomy
but all of those studies have tremendous
limitations and even the RCTs and and
this is why we have still the need to to
to to perform a multicenter RCT to
address which modality is best and and
obviously at the end of the day it
really boils down to tailoring you know
your approach to your individual patient
and be you know cognizant of what are
the limitations
and the resources that you have
available to you right so like I said
until very recently general anesthesia
was thought to be the bad guy it caused
more you know hemodynamic instability
because it dropped you know your blood
pressure causes more episodes of
hypotension also led to potentially as a
result you know to more morbidity at 90
days as well as mortality and and all
the complications related to intubation
like getting a pneumonia or
ventilator-associated pneumonia etc so
there are no RCTs to explore the
comparison and that as a matter of fact
the most recent guidelines that we have
regarding early you know thrombectomy in
patients with acute ischemic stroke came
from 2015 as a revision of the 2013 and
it stipulates that it might be
reasonable to actually consider
conscious sedation over general
anesthesia in thrombectomy x' so
procedural hypotension is bad and we
know that it makes sense and this is
actually a paper that was just published
in a Jnr and which shows that basically
a drop in blood pressure will inevitably
you know cause a detriment to to the
brain and to the to the 90-day outcome
or good outcome which in this case was
quantified using an Mrs of 0 to 2 so
functional independence at 90 days and
you can see that across the whole gamut
of skill severity is really when you
drop your map below a certain level
which is not really quantify where we
don't know exactly what and it very
likely varies you know depending on the
patient and the baseline you know blood
pressure of that patient but you will
cause a greater morbidity and as a
matter of fact you are four times more
likely to to have a bad outcome so an
MRIs of greater than two if you were if
you had the a at least a 10 millimeter
of mercury drop in your map there is a
meta-analysis that actually came up last
year that looked at 18 different studies
and that basically showed worst
neurological outcomes with general
anesthesia
and and there were more you know intra
procedural hypotension episode almost
you know an odds ratio of 1.4 you almost
doubled your 90-day mortality and you
have to your functional independence at
90 days the problem with those studies
are and I don't have all the points here
shown but first of all most of those
studies were retrospective second
there's a huge selection bias because
those studies usually in in those
studies the worse
strokes actually received a general
anaesthesia and the third point was that
most of those studies were done in the
priest and Retriever era so in this
forest plot here you can see highlighted
in green on the top is the studies that
basically included the priests and you
know studies and the bottom half is
those that pertain to the stent
Retriever era to the left of the
vertical line and that crosses the one
is studies that basically favored the
use of Mac or conscious sedation versus
the ones on the right that favored
general anaesthesia and you can see if I
had a pointer I could show you well
there that I want to point your
attention to the red circles here these
are the only two studies that actually
showed that there was a better outcome
using conscious sedation now one of them
crosses you know the one and so it's not
necessarily very you know statistically
significant but it there's a trend the
other one is definitely shows better
outcome with you know conscious sedation
in terms of good neurological outcome
meaning an mr s of zero to two at ninety
days okay and interestingly enough those
are the only two studies that were RCTs
the others are all retrospective and I
want a point I want to discuss just a
little bit more about one of those
studies which is appropriately called
siesta and basically was performed in
Germany it's a single Center study that
enrolled 150 patients and randomized
them between general anesthesia and
conscious sedation and their primary
outcome looked at nine
they actually I'm sorry looked at early
neurological improvement at 24 hours and
that was using a delta NIH Stroke Scale
so an actual scale at 24 hours - the NIH
Stroke Scale on admission and their
secondary outcome were more mortality at
90 days morbidity in 90 days as well as
feasibility and other metrics so the the
bottom line of this paper was that
there's actually no difference in the
two arms of treatment regarding early
neurological improvement meaning and at
night at 24 hours so comparing the NIH
Stroke Scale at 24 hours and on
admission and if you look at all the
subgroup that they analyzed there was
really also no difference okay including
the severity of the NIH Stroke Scale the
gender whether or not they got TPA and
how bad their stroke looked
radiographically based on the aspect
score using the garage hours here you
can actually see that at 90 day when
they did their secondary outcome the NRS
of 6 which equals death was actually the
same between the two arms and if you
look at the three first bars the lighter
blues you can see the mr-s of zero to
two which is the functional independence
and there is a statistical significance
or statistically significant improvement
with patient in the general anesthesia
group meaning that much more or much
more patients did better at 90 days and
were more functionally independent if
they had received general anesthesia
interestingly because this is in
contradiction to what the other
retrospective studies had shown before
so and specifically there was actually
no difference in the rate of
recanalization door to reperfusion time
which is extremely important even though
there was maybe longer door to puncture
time with general anesthesia
there was very importantly no more
episodes of hypotension using general
anesthesia compared to conscious
sedation and the length of stay whether
IC or total
say was the same and in terms of I
orogenic complications related to the
procedure itself like vessel rupture or
I CH there was actually no difference
the common and you know common sense
complications that you would expect from
each modality is that GA was fraught
with more hypothermia hypothermic
episodes obviously delayed extubation
ventilator associated pneumonia and more
thorough sees and all the complications
related to intubation
whereas Mac because you're lightly
sedating the patient there was more risk
of having patient movement but this
didn't seem to necessarily on truly
affect the patient the problems with
those are CTS the to our cities is that
well first of all it's very limited
generalizability because those studies
were performed in centers that were
highly skilled that had really high and
skilled you know neuro anesthesia teams
as well as neurointerventional lists
they as a result they had very low rates
of procedural hypotension and their door
to growing puncture time was under 10
minutes which is fairly remarkable and
the other problem was that there was a
high crossover rate meaning basically
those patients who started off with
conscious sedation and then had to be
converted because of X Y or Z you know
during the procedure to a general
anesthesia you had worse outcome because
you know you have to analyze those
patients with an intention-to-treat
analysis and and more delays related to
having to convert from one sedation to
the other and treating the patient was
probably nefarious for for the Mac arm
it was a 15 percent crossover compared
to less than 3 percent in all the other
retrospective studies that were
analyzing that meta-analysis and as I
said problems also with generalizability
came from the fact that these were
single Center studies and that they
usually had more experience with the GA
so my final recommendation is well
unfortunately we do not have really good
and strong evidence to date to suggest
or support the use of one
and if Caesar modality versus the other
however since we thought you know before
that general anesthesia was you know
deleterious and people try to shy away
from it and use conscious sedation there
is more recent data and stronger data to
support that it might actually not be
the case and the two might actually be
very you know similar and so so we we do
need obviously stronger data and
multicenter randomized controlled trials
in order to address the topic but in the
meantime it's really important to look
at your patient clinically okay what do
you think the patient will need and you
know require before the procedure starts
and obviously what are your Hospital
resources capabilities in terms of you
know first of all de anaesthesia team
then your intervention Elise and your
capability to perform neuro monitoring
thank you very much
[Applause]