Endovascular treatment: which is better for general anesthesia, conscious sedation or local anesthesia?

Don't want to miss Jie Ge's push? Click the blue word "Medical Neurology Channel" at the top to follow us and click the "···" menu in the upper right corner, and select "Set as Star" Ding! You have received the latest information from the agents on the front line of the brain! Abstract of this article: In benzodiazepine refractory status epilepticus, levetiracetam, fosphenytoin sodium, and sodium valproate are effective in the treatment of microembolic signals after successful endovascular thrombectomy does not affect the prognosis of the disease, but Can predict new embolic events.
Different anesthesia methods for acute ischemic stroke endovascular treatment (EVT) may affect functional prognosis.
Agents in the front line of the brain I found: Levetiraceil in benzodiazepine refractory status epilepticus Tan, fosphenytoin sodium, and sodium valproate are effective in treating status epilepticus (SE).
They are critically ill.
The first choice for clinical treatment is benzodiazepines, which are mainly used in the early stages.

However, status epilepticus, which is difficult to treat with benzodiazepines, has not been well studied.

This article was recently published in the New England Journal and is a multicenter randomized trial comparing levetiracetam, fosphenytoin sodium, and sodium valproate.

The main result is that there are no clinically significant seizures and improvement in level of consciousness within 60 minutes after the start of the drug infusion.

Calculate the posterior probability of the most effective or least effective for each drug.

Safe outcomes include life-threatening hypotension or arrhythmia, endotracheal intubation, recurrence of seizures, and death.

The results showed that a total of 384 patients were enrolled in the group and randomly assigned to receive levetiracetam (145 cases), fosphenytoin sodium (118 cases) or sodium valproate (121 cases).

Among the baseline characteristics, men accounted for 55%, children and adolescents (under 17 years of age) accounted for 39%, and 10% were determined to have psychogenic seizures.

The analysis of drug efficacy showed that 68 patients (47%) in the levetiracetam group, 53 patients (45%) in the fosphenytoin group, and 56 patients (46%) in the valproate group had their seizures terminated within 60 minutes And the level of awareness improved.

The most effective posterior probability of each drug is 0.
41, 0.
24 and 0.
35, respectively.

The median time from the start of the drug treatment to the termination of the seizure was 10.
5 minutes, 11.
7 minutes, and 7.
0 minutes, respectively, and there was no significant difference.

Therefore, in benzodiazepine refractory status epilepticus, the anticonvulsant drugs levetiracetam, fosphenytoin sodium, and sodium valproate can make about half of the patients stop seizures within 60 minutes, and these three The incidence of drugs and adverse events is similar.

 In the safety analysis, the fosphenytoin treatment group had more hypotension and intubation, while the levetiracetam group had a higher incidence of death than the other two groups, but these differences were not significant.

 Persistent seizures can not only affect the normal metabolism of cells, cause energy supply disorders in patients, and ultimately damage brain neurons, but also induce death due to circulatory failure, secondary infection, and internal environment imbalance.

Therefore, it is necessary to further study the choice of drug efficacy or safety.

A frontline agent stationed in the brain, I found that the microembolic signal after successful intravascular thrombectomy does not affect the prognosis of the disease, but can predict new embolic events.
Acute anterior circulation and ischemic stroke is a serious condition in acute cerebrovascular disease.
A type of poor prognosis, early and effective recanalization of blood vessels, saving the ischemic penumbra is the key to treatment.

Intravascular thrombectomy has been proven to be an effective treatment, but a review of studies found that only half of patients who showed signs of nerve recovery early after surgery and who achieved functional independence within 90 days, the prognosis of the disease is worthy of attention.

A prospective multi-center study recently published in "AHA/ASA Journals" shows.

Transcranial Doppler (TCD) was used to monitor microembolic signal (MES) for 30 minutes in patients with successful recanalization of intravascular thrombectomy (mTICI 2b-3) within 72 hours after surgery.
The main results include 90 days The modified Rankin scale score and the infarct volume of head ct at 24 hours.

The NIHSS scale, stroke recurrence within 90 days, transient ischemic attack or systemic embolism are also used to assess early prognosis.

The results showed that MES was detected in 43 (39%) of 111 patients, with a median of 4 times/h (interquartile range 2-12).

The main functional endpoint, the sequential shift of mRS at 90 days, was not significantly different between the MES-positive group and the MES-negative group (adjusted OR=1.
06, 95%CI=0.
48-2.
34, P=0.
85).

The proportion of patients who were functionally independent within 90 days (mRS, 0-2) also had no significant difference (adjusted OR=0.
52, 95%CI=0.
19-1.
39, P=0.
19).

There was no significant correlation between the existence of MES and the probability of obvious recovery of early neurological function (adjusted OR=1.
09, 95%CI=0.
43-2.
79, P=0.
86).

In the 24-hour CT scan, the infarct volume of the MES-positive and MES-negative subgroups was similar (median 14[1-67]vs14[7-47]mL, corrected β=-11.
2, 95%CI=-46.
6 to + 22.
9, P=0.
51).

 Patients were followed up for 90 days, 8 cases of recurrent ischemic stroke, 1 case of transient ischemic attack, most of the recurrences occurred in the MES positive group (7/43 [16%] vs 2 of the MES negative group 68[3%]).

Among the 7 cases of cerebral ischemia recurrence in the MES positive group, 4 cases (57%) had the same stroke location as the initial TCD examination.

Time-related risk changes showed that the risk of embolic events in the MES positive group was significantly increased (log-rank test P=0.
02), especially the risk of ischemic stroke/TIA (log-rank test P=0.
01).

Compared with MES-negative patients, the risk of ischemic stroke/transient ischemic attack in MES-positive patients is 8 times higher (adjusted HR=8.
22, 95%CI=1.
55-43.
9, P=0.
01), and all embolic events will occur The overall risk is 6 times higher (adjusted HR=6.
73, 95%CI=1.
63-27.
8, P=0.
01).

There is no correlation between the existence of MES and all-cause mortality.

 This study explains that the presence of microemboli in the acute phase seems to be an important risk factor for further embolic events in the weeks and months after stroke.
This finding is helpful for risk stratification and patient management.

The frontline agent in the brain I discovered: Different anesthesia methods for acute ischemic stroke (EVT) may affect the functional prognosis.
Endovascular therapy (EVT) is a safe and effective method for the treatment of anterior circulation ischemic stroke.

However, the best strategy for anesthesia management during EVT is unclear.

The three most common anesthesia methods are: general anesthesia (GA), conscious sedation (CS) and local anesthesia (LA).

The 2015 American Heart Association guidelines pointed out that the choice of anesthesia method should be based on the individual characteristics of the patient, and additional evidence is needed to determine the best standard method.

Recently, a prospective multi-center randomized clinical trial (MR-CLEAN) published in "Neurology" conducted data on patients with acute anterior circulation occlusion and ischemic stroke who underwent endovascular treatment in the Netherlands from March 2014 to June 2016.
analysis.

The main result is the 90-day modified Rankin score.

Other observed indicators include NIHSS, eTICI, symptomatic intracranial hemorrhage (sICH), ischemic stroke progression, pneumonia, and 90-day mortality.

The results showed that a total of 1376 patients were enrolled, and the anesthesia methods were LA 821 (60%), GA 381 (28%) and CS 174 (13%).

Among patients who tried thrombosis recovery, the most common successful reperfusion (eTICI≥2B) was GA (64%), followed by LA (59%), and CS (52%) (p=0.
02).

Compared with GA and CS, the start time of EVT (LA200, GA 225, CS 210 minutes) and the start time of reperfusion (LA258, GA 287, CS 272 minutes) in the LA group were shorter than those in the GA and CS groups.

 Compared with LA, GA and CS were associated with a lower functional prognosis with a 90-day modified Rankin scale score (GA-coradj0.
75, 95%CI0.
58-0.
97; CS-coradj0.
45, 95%CI0.
33-0.
62 ).

The functional prognosis of CS is worse than that of GA (coradj 0.
60, 95% CI 0.
42-0.
87).

A 90-day mRS score was performed on 1264 patients.

Functional independence (mRS score 0-2) was 41% in the LA group, 35% in the GA group, and 25% in the CS group (p<0.
01).

Compared with the GA group (14%) and the CS group (9%), the LA group (23%) had a higher frequency of mRS scores of 0-1 (p<0.
01).

 In the safety analysis, the incidence of sICH was similar among the groups.

The incidence of pneumonia in the CS group was higher (20% vs 11%LA vs 10%GA), p<0.
01.

Compared with GA (32%) and CS (36%), LA (27%) had the lowest mortality rate (p=0.
04).

 The author stated that the article explains that the functional prognosis of LA in patients with acute ischemic stroke undergoing EVT is better than systemic sedation.

Compared with CS, LA has obvious advantages, but compared with GA, this advantage is not so prominent.

Moreover, thrombectomy may be painful under LA, and future research should investigate the possible psychological effects after EVT.

References: [1]Kapur J, Elm J, Chamberlain JM, et al.
Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus[J].
New England Journal of Medicine, 2019, 381(22): 2103-2113.
[2 ]Sheriff F, Diz-Lopes M, Khawaja A, et al.
Microemboli After Successful Thrombectomy Do Not Affect Outcome but Predict New Embolic Events[J].
Stroke, 2019: STROKEAHA.
119.
025856.
[3]Goldhoorn RJB, Bernsen MLE, Hofmeijer J, et al.
Anesthetic management during endovascular treatment of acute ischemic stroke in the MR CLEAN registry[J].
Neurology, 2019.