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Abstract
Purpose of Review Endovascular therapy (EVT) for acute ischemic stroke caused by large vessel occlusion is a powerful and evidence-based tool to achieve reperfusion and results in improved neurologic outcome. Focus has now shifted toward optimizing the procedure. We reviewed the relevant current literature on periprocedural stroke care such as pretreatment with IV tissue plasminogen activator (tPA), choice of anesthesia, ventilation strategy, and blood pressure management.
Recent Findings IV tPA should not be withheld in a patients with stroke eligible for EVT. A meta-analysis of randomized trials on general anesthesia (GA) vs procedural sedation has shown better neurologic outcomes with protocol-based GA in centers with dedicated neuroanesthesia teams. There are no data from randomized trials on blood pressure control, but according to available evidence, systolic blood pressure should probably be held at >140 mm Hg during the procedure and <160 mm Hg after reperfusion. In ventilated patients, extreme deviations from normoxemia and normocapnia should be avoided.
Summary Periprocedural care influences the outcome after EVT for large vessel ischemic stroke. More evidence from prospective ongoing and future studies is urgently needed to identify its optimization.
Glossary
- AIS=
- acute ischemic stroke;
- ANSTROKE=
- Sedation Versus General Anesthesia for Endovascular Therapy in Acute Stroke–Impact on Neurological Outcome;
- CI=
- confidence interval;
- DIRECT-MT=
- Direct Intra-Arterial Thrombectomy in Order to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals;
- EVT=
- endovascular therapy;
- EXTEND-IA TNK=
- Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke;
- GA=
- general anesthesia;
- GOLIATH=
- General or Local Anaesthesia in Intra Arterial Therapy;
- HERMES=
- Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke;
- LVO=
- large vessel occlusion;
- MAP=
- mean arterial blood pressure;
- MR CLEAN=
- Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands;
- mRS=
- modified Rankin Scale;
- OR=
- odds ratio;
- PS=
- procedural sedation;
- SBP=
- systolic blood pressure;
- sICH=
- symptomatic intracranial hemorrhage;
- SIESTA=
- Sedation Versus Intubation for Endovascular Stroke Treatment;
- THRACE=
- Trial and Cost Effectiveness Evaluation of Intra-Arterial Thrombectomy in Acute Ischemic Stroke;
- tPA=
- tissue plasminogen activator
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
- Received June 28, 2020.
- Accepted in final form February 24, 2021.
- © 2021 American Academy of Neurology
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