Anaesthesia for mechanical thrombectomy- NICE/ AA

Question 1

Mechanical Thrombectomy- Inclusion Criteria

Answer 1

Proximal occlusion of the internal carotid or middle cerebral artery and…
- Thrombectomy can occur within 6 hours of symptom onset
- Or CT angio demonstrates salvageable brain within 12 hr of symptom onset
- Or perfusion studies demonstrate salvageable brain within 24 hours of symptom onset
and…
- There has been an inadequate response to thrombolysis
- Patients are unable to receive IV thrombolysis because they are on anticoagulants
and…
- New disability (National institute of health stroke score <5)
- Previously independent (Modified Rankin <3)

Question 2

Mechanical Thrombectomy- Exclusion Criteria

Answer 2

• No appropriate vascular access or contraindications to arterial puncture
• No proximal intracranial large artery occlusion

Question 3

GA for Mechanical Thrombectomy- Advantages

Answer 3

• Airway protection
• Ability to control respiration
• Immobile patient- reduce risk of complications and shorter recanalisation time
• Dedicate anaesthetic input and ability to manipulate physiology

Question 4

GA for Mechanical Thrombectomy- Disadvantages

Answer 4

• Longer door to recanalisation time
• Greater potential for hypotension (esp on induction)
• Inability to assess neurology
• Greater risk of post-op cognitive dysfunction
• Greater manpower requirements

Question 5

Conscious sedation for Mechanical Thrombectomy- Advantages

Answer 5

• Shorter door to groin puncture time
• Less haemodynamic instability
• Ability to continuously assess neurology

Question 6

Conscious sedation for Mechanical Thrombectomy- Disadvantages

Answer 6

• Patient discomfort and distress
• Patient movement
• Risk of hypoxia, airway obstruction, aspiration

Question 7

Anaesthetic considerations for mechanical thrombectomy

Answer 7

• Remote site issues
• Radiation exposure
• High contrast burden for patient
• Patients may be aphasic- communication, anaesthetic history, consent
• Unfasted
• Lack of pre-op investigations
• IR may request aspirin loading, or GPIIb/ IIIa inhibitors

Question 8

Goals for anaesthesia for mechanical thrombectomy

Answer 8

• AAGBI monitoring
• Shouldn’t delay for an arterial line unless specific patient reason
• NIBP 2.5mins
• RSI
• pEEG to reduce overall GA requirements
• Aim systolic BP 140-180, MAP >70 (use vasopressor infusion)
• High fluid load from IR, fluid restrict
• Patient may have received thrombolysis can bleed

Question 9

Post-operative considerations following Mechanical Thrombectomy

Answer 9

• Should be transferred to a stroke unit as soon as possible to receive stroke rehab (physio, OT, swallow assessment etc)
• If ongoing neuro-concerns or low GCS may need ICU
• No clear BP targets, keep sys <180
• Monitor renal function given high contrast load