Endovascular Thrombectomy (Acute Ischemic Stroke)
Patient phenotype
LVO (large vessel occlusion) acute stroke within thrombectomy window (< 24 hr selected with imaging). NIHSS often ≥ 6. Elderly, AF, HTN, DM common. May be on tPA already.
Procedure
Femoral artery access, catheter to ICA/MCA/basilar, stent retriever or aspiration of thrombus. Time-critical: door-to-recanalization < 90 min target. ~30-90 min.
Anesthetic plan
Highly debated: GA vs MAC/conscious sedation. Modern evidence (GASS, AnStroke) shows similar outcomes. MAC if cooperative + stable; GA for uncooperative, decreased LOC, posterior circulation, airway concerns. Maintain BP strictly: SBP 140-180 pre-recanalization, < 140-160 post.
Setup
- ·A-line (preferably contralateral to access)
- ·PIV (sometimes a-line is the only line at start)
- ·Vasoactive drugs ready: NE, nicardipine, esmolol
- ·ETT + LMA + airway cart at hand
- ·Off-floor monitoring
Biggest concerns by phase
BP target — strict
Pre-recanalization: SBP 140-180 (perfusion of penumbra). Post-recanalization: SBP < 140-160 (reperfusion injury + bleed prevention). Tight window — vasopressor + vasodilator both ready.
MAC vs GA decision
MAC: faster door-to-puncture, avoid intubation hemodynamic insult, but motion + airway risk. GA: stable, but BP drops at induction can drop CPP. Local protocol + patient factors.
BP management during induction (if GA)
Drop in BP during GA induction → infarct expansion. Etomidate + low-dose fentanyl + roc, A-line PRE-induction. Pre-position pressors. MAP not below 70.
Patient cooperation in MAC
Aphasic or agitated patients can't cooperate. Restraints + light sedation may suffice; if not, convert to GA.
Reperfusion management
Once recanalized: BP target tightened (SBP < 140-160). Nicardipine drip preferred. Avoid hypotension swings.
Postop neuro check + ICU
Document neuro before/after. ICU disposition + close BP control × 24h. Repeat imaging if neuro change (hemorrhagic conversion).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
72-yo F, NIHSS 18, L MCA LVO on CTA, last known well 3h ago, received tPA. To IR for thrombectomy. SBP 195. Plan?
What an examiner probes for
- ▹BP target pre vs post recanalization
- ▹MAC vs GA discussion
- ▹A-line first
- ▹Pressor + vasodilator drips ready
- ▹Strict BP control + neuro monitoring
Sources
- AHA/ASA Stroke Thrombectomy Guidelines 2019
- Anesth Analg Stroke Anesthesia Review
Anatomy reference
Sourced reference images. 4 matches for "brain artery cerebral".
