thrombectomy for ischemic stroke and anaesthesia

Audit/Research projects July-December 2013.

Dr Wahid Altaf Dr Sinead Galvin

Stroke

• Sudden death of cells due to lack of oxygen.

• Manifesting as focal or global disturbance of cerebral function lasting for more than twenty four hours or leading to death.

• Survival of brain cells depends on time since lack of oxygen.

Stroke in Ireland

• Annual number of stroke patients in Ireland is around 10,000.87% ischemic stroke.

• Annual number of deaths from stroke is 2000.

• Number of disabled patients secondary to stroke around 30,000.

Risk factors for Ischemic stroke

Non-Modifiable• Age• Male sex• Race• Inheritance

Modifiable• Hypertension• Daibetes Mellitus• Cardiac disease (AF)• Cigarette smoking• Obesity• Increase homocysteine • Inc Cholesterol.

• Its early diagnosis is important as its treatment is dependent on the time elapsed since the onset of the symptoms. Delay in diagnosis and treatment translates into increased neuronal loss and thereby increased morbidity.

• Reperfusion remains the mainstay of acute ischemic stroke treatment .

Diagnosis and treatment

Time is Brain!!!!• The average duration of non-lacunar stroke evolution is 10 hours (range 6 to 18 hours), and the average number of neurons in the human

forebrain is 22 billion.• In each minute, 1.9 million neurons, 14 billion synapses,

and 12 km (7.5 miles) of myelinated fibers are destroyed. • Compared with the normal rate of neuron loss in brain

aging, the ischemic brain ages 3.6 years each hour without treatment.

Time is Brain!!!!!

Treatment options available.• IV rtPA therapy.

• Mechanical clot disruption with IAT.

• Thrombectomy.

THROMBUS

Mechanical thrombectomy

• Recanalization by mechanical thrombectomy may occur due to combination of thrombus fragmentation, thrombus retrieval, and enhancement of fibrinolytic penetration.

• FDA cleared many devices for recanalization of arterial occlusion in patients with ischemic stroke.

The Evidence ????

• NINDS iv tpa <3hours.

• ECASS III iv alteplase 3-4.5 hours.

• PROACT II ia pro uk <6hours.

• MERCI thrombectomy, 8hours.

General anesthesia for Intervention in Stroke- Intra-arterial thrombolyis and Mechanical thrombectomy in Beaumont Hospital

Background• Avoid anesthesia Speed of whole process Avoid anesthetic drug effects- hypotension or effect on cerebral activity • Need for anesthesia can’t be ignored.• Retrospective review on type and number of

patients who got general anesthesia during last three years for clot retrieval in radio-intervention suite of Beaumont hospital.

• Identify demand, issues and future.

Clot retrieval in Beaumont Hospitalfrom April 2010 to Sept 2013.

• Total number of cases done 107.

Admission route

GA patients admission route

Distribution in 24 hours

Demographics

Male 56

Female 51

Age yrs (Average) 26-87 (62)

Demographics of patients for GAMale 5

Female 7

Age years (Average) 32-73(55)

Overall Risk factorsRisk factor Number of patients

High blood pressure 40

High cholesterol 18

Previous CVA 11

Ischemic heart disease 12

Atrial Fibrillation 26

Diabetes Mellitus 6

Smoking 20

Risk factors in GA patientsRisk factor Number of patients

Hypertension 6

Ischemic heart disease 2

Atrial fibrillation 2

Smoking 1

Dyslipidemia 3

Stroke scale of patients (NIHSS)

NIHSS at presentation of all patients.

NIHSS at presentation of GA patients

Stroke characteristics-Vessel involved

Stroke characteristics Number of patients

Right sided 51

Left sided 56

Middle cerebral artery M1 59

Middle cerebral artery M2 13

Internal carotid artery 35

Basilar artery 5

Multiple vessels 42

Stroke characteristic of GA patientsVessel Involved

Stroke characteristics Number of patients

Right 8

Left 4

Internal carotid artery 6

Middle cerebral artery M1 6

Vertebral artery 1

Basilar artery 1

Planned Vs Rescue GA

IV Thrombolysis pre procedure

IV Thrombolysis before GA.

Hemodynamic parameters in GA patients during the procedure

Parameter Values Range (Average) mmHg

Systolic BP 100-140 (120)

Diastolic BP 60-90 (65)

Mean BP 73-106 (83)

Vasopressors used to maintain blood pressure in GA patients

ComplicationsComplication Number of patients

Procedural complications 15

Haemorrhage 28

Clinically significant haemorrhage 12

ICU Admission post procedure of GA patients

MRS at 3 months.

MRS of GA patients

Prognosis overall

Prognosis of GA patients

Prognosis with intra-op Blood pressure

Mean Arterial BP (mmHg)

Survived Dead Unknown

< or= 80 1 4 1

>80 5 1 0

Issues important to us.• Increasing demand over the years.• Out of hours service needed.• High ASA grade of these patients.• Failed IV thrombolysis before clot retrieval and consequences

thereof.• Internal carotid and middle cerebral artery involvement in

majority.• Hemodynamic parameters to target/Blood glucose control

and means to achieve the same/maintaining normothermia.• Need for ICU/Ventilation post procedure.

Future

• Our demand to provide anesthesia for sick patients may increase with time.

• Develop standard procedures and protocols.

• Canadian multi-centric trial for outcome from clot retrieval.

• Clot retrieval in interventional cardiology.

Quality improvement maneuver

• Safer and standard anesthetic practice Standard monitoring as per AAGBI. IV canula with IV fluids running via 3 way tap. Anesthetic machine checked every day and ready in high risk patients. Emergency drugs/Airway tray ready to use.