Critical Care and Resuscitation

E   Narrative Review Article

Management of Acute Ischemic Stroke–Specific

Focus on Anesthetic Management for
Mechanical Thrombectomy
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Jerrad Businger, DO,* Alexander C. Fort, MD,† Phillip E. Vlisides, MD,‡

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Miguel Cobas, MD, FCCM,† and Ozan Akca, MD, FCCM§

Acute ischemic stroke is a neurological emergency with a high likelihood of morbidity, mortality,
and long-term disability. Modern stroke care involves multidisciplinary management by neurologists,
radiologists, neurosurgeons, and anesthesiologists. Current American Heart Association/American
Stroke Association (AHA/ASA) guidelines recommend thrombolytic therapy with intravenous (IV)
alteplase within the first 3–4.5 hours of initial stroke symptoms and endovascular mechanical
thrombectomy within the first 16–24 hours depending on specific inclusion criteria. The anesthesia
and critical care provider may become involved for airway management due to worsening neurologic
status or to enable computerized tomography (CT) or magnetic resonance imaging (MRI) scanning,
to facilitate mechanical thrombectomy, or to manage critical care of stroke patients. Existing data
are unclear whether the mechanical thrombectomy procedure is best performed under general anes-
thesia or sedation. Retrospective cohort trials favor sedation over general anesthesia, but recent
randomized controlled trials (RCT) neither suggest superiority nor inferiority of sedation over general
anesthesia. Regardless of anesthesia type, a critical element of intraprocedural stroke care is tight
blood pressure management. At different phases of stroke care, different blood pressure targets are
recommended. This narrative review will focus on the anesthesia and critical care providers’ roles in
the management of both perioperative stroke and acute ischemic stroke with a focus on anesthetic
management for mechanical thrombectomy. (Anesth Analg 2020;131:1124–34)

GLOSSARY
AHA/ASA = American Heart Association/American Stroke Association; AIS = acute ischemic stroke;
AnStroke = Anesthesia during Stroke; ASPECTS = Alberta Stroke Program early CT score; BP = blood
pressure; CANVAS = Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic Stroke; CI
= confidence interval; CT = computerized tomography; CTP = computerized tomography perfusion;
DAWN trial = Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing
Neurointervention With Trevo; DBP = diastolic blood pressure; DEFUSE 3 trial = Endovascular Therapy
Following Imaging Evaluation for Ischemic Stroke; DWI = diffusion weighted imaging; ECG = electro-
cardiogram; ED = emergency department; EMS = emergency medical services; ER = emergency
room; ESO = European Stroke Organization; GA = general anesthesia; GCS = Glasgow coma scale/
score; GOLIATH = General or Local Anesthesia in Intra Arterial Therapy; HERMES = Highly Effective
Reperfusion Evaluated in Multiple Endovascular Stroke Trials; ICA = internal carotid artery; ICU =
intensive care unit; INR = international normalized ratio; IR = interventional radiology; IV = intrave-
nous; LVO = large-vessel occlusion; MAC = monitored anesthesia care; MAP = mean arterial pres-
sure; MCA = middle cerebral artery; mNIHSS = modified National Institute of Health Stroke Scale;
MRI = magnetic resonance imaging; MT = mechanical thrombectomy; NIHSS = National Institute of
Health Stroke Scale; NR = nonrandomized; OR = odds ratio; OT = occupational therapy; PT = pro-
thrombin time; PWI = perfusion weighted imaging; RCT = randomized controlled trials; SBP = systolic
blood pressure; SIESTA = Sedation versus Intubation for Endovascular Stroke Treatment; SNACC
= Society for Neuroscience in Anesthesia and Critical Care; SNIS = Society of Neurointerventional
Surgery; Spo2 = pulse oximeter saturation; TCI = target-controlled infusion; TIA = transient ischemic
attack; TICI = thrombolysis in cerebral infarction scale; tPA = tissue plasminogen activator

From the *Division of Critical Care, Department of Anesthesiology &
Perioperative Medicine, Neuroscience Intensive Care Unit (ICU),
Comprehensive Stroke Center, University of Louisville, Louisville,
Kentucky; †Department of Anesthesiology, University of Miami, Miami,
Florida; ‡Department of Anesthesiology, University of Michigan, Ann
Arbor, Michigan; and §Department of Anesthesiology and Perioperative
Medicine, Stroke ICU, University of Louisville, Louisville, Kentucky.
Accepted for publication May 6, 2020.
Funding: None.
The authors declare no conflicts of interest.
Copyright © 2020 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000004959
J. Businger, A. C. Fort, and P. E. Vlisides contributed equally and share first
authorship.
The panel version of this narrative review, titled “SOCCA Panel: Critical Care
Anesthesiologist & Acute Care Continuum of Complex Stroke Patient,” was
presented at the International Anesthesia Research Society (IARS), May 19,
2019, by the same contributors.
Reprints will not be available from the authors.
Address correspondence to Miguel Cobas, MD, FCCM, Department of Anes-
thesiology, University of Miami, 9380 SW 150th St, Ste 250, Kendall, FL 33176.
Address e-mail to mcobas@med.miami.edu; or Ozan Akca, MD, FCCM, De-
partment of Anesthesiology, University of Louisville Hospital, 530 S Jackson
St, Louisville, KY 40202. Address e-mail to ozan.akca@louisville.edu.

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 EE Narrative Review Article
A
cute ischemic stroke (AIS) is the fifth lead-
ing cause of mortality in the United States,
and stroke-related costs are estimated as high
as $34 billion each year.1 This estimate includes the
health care service expenses, medicines to manage
stroke, and missed workdays.1
In AIS management, immediate medical attention,
emergent transfer to a stroke care facility, and early
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access to long-term functionality-modifying therapies
form the key care concepts. Initial hemodynamic and
respiratory stabilization, prompt assessment for hem-
orrhagic or occlusive etiology, and rapid recanaliza-
tion therapy—if indicated—are critical in acute stroke
management.2–4
Optimal early stroke care—as defined by American
Heart Association/American Stroke Association
(AHA/ASA) guidelines—requires extensive multidis-
ciplinary collaboration between emergency medicine
and stroke teams so that care protocols are initiated in
a timely fashion.3 Initial stroke care typically includes
a neurologist examination, rapid glucose assessment,
and a noncontrast computerized tomography (CT)
scan to exclude an intracranial hemorrhagic event. If
no contraindications are present, an AIS patient then
receives intravenous (IV) tissue plasminogen activator
(tPA; alteplase) treatment and may undergo further
assessment under CT-angio or CT-perfusion scanning
to determine whether a large-vessel occlusion (LVO) is
present (eg, internal carotid, middle cerebral artery),
which can be treated via mechanical thrombectomy.
Anesthesia and critical care team involvement may
occur either during transfer from the emergency room
(ER) to the neurointerventional suite (interventional
radiology [IR]) for mechanical thrombectomy or on
triage to the neuroscience or stroke intensive care unit
(ICU) or when emergent decompression is needed if
there’s a threat for herniation. Due to requirements
for frequent and close monitoring, stroke patients are
not followed on the regular floor even IV alteplase
and mechanical thrombectomy are not performed.
Supportive care for stroke patients involves observa-
tion for changes in mental status, careful management
of blood pressure, assessment for adequacy of airway
reflexes, and maintenance of oxygenation, normother-
mia, and normoglycemia.
In this narrative review, we summarize current opti-
mal management of AIS with a focus on anesthetic
management for thrombectomy. Additionally, we
address the acute management of perioperative stroke.
ACUTE MANAGEMENT OF ISCHEMIC STROKE
Understanding the pathophysiology of AIS is para-
mount to its successful management. After the initial
ischemic insult, perfusion to the ischemic area may be
reduced due to cerebrovascular occlusion, cytotoxic
edema from the injured brain, and impaired cerebral
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autoregulation. This cascade of events may further
worsen areas of brain with already threatened perfu-
sion and cause them to progress to irreversible injury
unless reperfusion is achieved promptly.
Management of AIS rests on the successful comple-
tion of a 4-phase care plan (Table 1).
Admission
Time is of the essence when minimizing neuronal loss in
AIS. The current guidelines by the AHA/ASA3 strongly
recommend public use of 911 calls in any suspicion of
stroke signs, and the guidelines suggest that dispatchers
prioritize potential stroke calls. A 2015 US-based study of
184,179 possible stroke calls found a median emergency
medical service (EMS) response time (911 call to emer-
gency department [ED] arrival) of 36 minutes, which is
considered long.5 Ideally, the goal “on-scene response
time” is within 15 minutes—unless there are extenuat-
ing circumstances or extrication difficulties—and the
“total on-scene time” should not exceed 15 minutes.6 For
patients in nonurban areas, challenges remain in stroke
recognition and timely access to patients. Utilization of
stroke assessment tools by EMS teams has increased
stroke recognition and is therefore strongly encouraged.7
Initial Management
Once the patient has been brought to the hospital, the
most important goal after initial clinical assessment
and neurological examination is to determine whether
a patient is a candidate for thrombolysis and recanali-
zation. Initial clinical examination includes the use of
a stroke severity scale such as the National Institute
of Health Stroke Scale (NIHSS), which includes a
brief set of consciousness, motor, sensory, vision, and
speech assessments.
Major contraindications for chemical thromboly-
sis via intravenous tPA are subarachnoid or intracra-
nial hemorrhage, active internal bleeding, prior stroke
(within last 3 months), mass lesions of brain, major sur-
gery within the past 15 days, persistent hypertension
(systolic blood pressure [SBP] >185 mm Hg, diastolic
Table 1.  Four Phases of Acute Ischemic Stroke
Management2,3
Management of AIS rests on the successful completion of well-structured
and defined approach, which can roughly be divided into 4 phases:
• Admission: From the initiation of symptoms (last known well) to
hospital arrival
• Initial Management: From the definitive diagnosis of AIS to the
initiation of recanalization attempts by thrombolysis (IV alteplase)
and/or mechanical thrombectomy
• Recanalization: (1) thrombolysis with IV alteplase (tPA); (2) assessment
for LVO; (3) mechanical thrombectomy for recanalization of LVO
• Postrecanalization: Multisystem management of successfully or
partially recanalized, and not recanalized AIS by multidisciplinary
expert care team
Abbreviations: AIS, acute ischemic stroke; IV, intravenous; LVO, large-vessel
occlusion; tPA, tissue plasminogen activator.
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 Stroke and Mechanical Thrombectomy

Table 2.  Recommendations for Endovascular Treatment of LVO Stroke16

Recommendations for Endovascular Treatment of LVO Stroke With Mechanical Thrombectomy
Time from Symptom Onset
• For anterior circulation AIS, thrombectomy indicated in select patients up to 16 h (class I, level A), and 24 h from last known well (class IIa, level B).
Imaging
• In patients with anterior circulation AIS within the first 6 h and either CT ASPECTS ≥6, MRI DWI ASPECTS ≥6, or significant penumbral to core
mismatch on advanced perfusion imaging (CT-perfusion or MRI-DWI-PWI), thrombectomy is indicated (class I, level A).
• In patients with anterior circulation AIS due to intracranial ICA and/or M1 occlusion within 6–24 h of symptom onset who meet the advanced MRI
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DWI-PWI or CTP imaging criteria for DAWN or DEFUSE 3, thrombectomy is indicated (class I, level B).
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• Thrombectomy may be indicated in carefully selected patients with anterior circulation AIS within 6–24 h of symptom onset who do not meet
imaging criteria for DAWN and DEFUSE 3 but otherwise have a “favorable” imaging profile such as CT ASPECTS of 6–10, MRI DWI ASPECTS of
6–10, or small (<70 mL) core infarct on advanced MRI DWI-PWI or CTP imaging (class IIb, level B-NR).
Location of LVO Stroke
• Thrombectomy is indicated in patients with occlusions of the ICA and M1/M2 MCA (class I, level A).
Stroke severity
• Thrombectomy is indicated in patients with anterior circulation LVO with NIHSS score ≥6 (class I, level A).
Age
• Age >80 y should not be used as a contraindication for thrombectomy (class IIa, level A).
Abbreviations: AIS, acute ischemic stroke; ASPECTS, Alberta Stroke Program early CT score; CT, computerized tomography; CTP, computerized tomography
perfusion; DAWN trial, Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo; DEFUSE 3 trial,
Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke; DWI, diffusion weighted imaging; ICA, internal carotid artery; LVO, large-vessel occlusion;
MCA, middle cerebral artery; MRI, magnetic resonance imaging; NIHSS, National Institute of Health Stroke Scale; NR, nonrandomized; PWI, perfusion weighted
imaging.

blood pressure [DBP] >110 mm Hg), history of bleed-
ing or coagulation problems (platelets <100,000, inter-
national normalized ratio [INR] >1.7, and prothrombin
time [PT] >15), hypoglycemia (glucose <50 mg/dL), and
NIHSS<6. The NIHSS should be ≥6 to exclude the pos-
sibility of other medical problems causing temporary
or focal neurological deficits such as transient ischemic
attack (TIA), complex migraine, or even a Bell’s palsy.
Since the benefits of both IV alteplase and mechani-
cal thrombectomy are time dependent, hospitals should
strive to perform brain-imaging studies within 20 min-
utes of arrival in the ER for patients who are poten-
tial candidates for either treatment. Hypoglycemia
may mimic stroke symptoms. Therefore, ASA/AHA
guidelines suggest assessment for hypoglycemia
before consideration for IV tPA treatment. If neurolog-
ical symptoms persist (NIHSS >6) after hypoglycemia
treatment, stroke diagnosis can be reconsidered.
Ideally, eligible patients should be treated as soon
as they are identified, and current recommendations
propose that ≥50% of patients brought to the hospital
for AIS should receive IV alteplase within 60 minutes
of arrival (door-to-needle time). Although a times-
pan of 60 minutes seems short, a bundle of key best
practices8 to reduce door-to-needle time have been
developed by the Target Stroke initiative, a national
collaborative effort between the AHA and multiple
hospitals. Implementation of this initiative has signifi-
cantly increased the number of AIS patients treated
within 60 minutes of arrival. 9,10
Recanalization
The time window for patients to receive IV alteplase
extends ≤4.5 hours from the onset of symptoms, but
efficacy decreases with increasing delay.11 Currently,
administration of IV alteplase from 3–4.5 hours after
symptoms is recommended only for patients ≤80
years of age who do not have a history of both dia-
betes mellitus and prior stroke, are not taking oral
anticoagulants, have a NIHSS score ≤25, and have an
ischemic injury involving no more than one-third of
the middle cerebral artery territory on CT scan, since
these conditions may increase the risk of bleeding.
During this phase of stroke management, anesthe-
siologists may be part of the acute stroke response
team or assist in management of hemodynamic and
respiratory instability. Patients with large strokes
affecting level of consciousness or those with brain-
stem dysfunction may need airway protection and
may require mechanical ventilation to maintain the
recommended oxygen saturation target of ≥94%.
However, in patients with pulse oximeter saturation
(Spo2) >94%, additional oxygen supplementation
does not improve outcomes.12 The target blood pres-
sure should be <185/110 mm Hg before IV alteplase
therapy is initiated, and <180/105 mm Hg for the
first 24 hours after administration.13,14 Hyperthermia
should be avoided and, if present, treated.15 At this
point, there is no role for hypothermia in the manage-
ment of AIS.
Patients whose neurological examination suggest a
potential LVO are potential candidates for mechani-
cal thrombectomy, and CT-angiography should be
performed.
Criteria for mechanical thrombectomy are listed in
Table 2. Similar to thrombolysis, shorter times from
symptom onset to endovascular therapy are associ-
ated with improved outcomes. Due to results from
two 2018 randomized trials, however, the window in
which mechanical thrombectomy has improved out-
comes17,18 can be, in some cases, as long as 24 hours
after the onset of symptoms.

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 EE Narrative Review Article
Postrecanalization
The patient with AIS should be monitored in an ICU,
a stroke unit or a location where frequent hemody-
namic, respiratory, and neurological assessments can
be performed. Blood pressure monitoring is recom-
mended every 15 minutes for the first 2 hours from the
starting point of IV tPA (alteplase) therapy, then every
30 minutes for the next 4 hours, and finally every hour
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thereafter until completion of the first 24 hours.2
In patients who undergo mechanical thrombec-
tomy, it is reasonable to maintain the SBP ≤160 mm
Hg for patients who are successfully recanalized (ie,
thrombolysis in cerebral infarction [TICI] score = 2b/3)
for 24 hours after the procedure. If there is any intra-
cerebral hemorrhagic lesion, then SBP goals should be
lower than 140 mm Hg. If recanalization was incom-
plete (ie, TICI ≤2a), then BP goals are similar to post IV
tPA treatment goals (<180/105 mm Hg; Table 5).
After thrombectomy, aspirin is indicated 24–48 hours
after the procedure if no primary contraindications are
present. Patients should be monitored for potentially
serious complications such as seizures, intracranial
bleeding, and cerebral/cerebellar edema. Standardized
prophylactic antiseizure pharmacotherapy is not recom-
mended after AIS.15 Ventriculostomy may be performed
in patients with signs of hydrocephalus, and decompres-
sive craniotomy/craniectomy is also an option when
intracranial pressures are difficult to control.
ANESTHETIC MANAGEMENT OF MECHANICAL
THROMBECTOMY
Mechanical thrombectomy for ischemic stroke is cur-
rently the standard of care among patients presenting
with LVO in the anterior circulation when eligibility
requirements are met3 (Table 2).
Whether anesthetic choice affects the outcome of
mechanical thrombectomy is an ongoing question.
Potential advantages of sedation or monitored anes-
thesia care include more rapid time to intervention,
less anesthetic effect on blood pressure, and the ability
to monitor the mental status directly. Advantages of
general anesthesia include definitive airway protection
and control of gas exchange and patient movement.
Current clinical evidence is mixed with respect
to this question. Early retrospective cohort studies
found general anesthesia to be inferior to sedation
and resulting in worse neurologic outcomes and
mortality.19–21 Subsequently, however, 3 single-cen-
ter randomized trials comparing general anesthesia
to conscious sedation and its effects on functional
outcome disputed the initial retrospective findings.
These randomized trials suggested that general anes-
thesia was not harmful, and functional outcome was
the same or possibly better in the patients undergo-
ing general anesthesia.22–24 Although the time to groin
puncture was increased with general anesthesia,
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door-to-reperfusion time and duration of the throm-
bectomy procedure were similar.
The reasons for discrepancies between retrospec-
tive cohorts and prospective randomized trial results
are unclear. However, among all randomized con-
trolled trials, intraprocedural management was explic-
itly protocolized within both the general anesthesia
and conscious sedation arms. In contrast, use of seda-
tives, analgesics, and anesthetics are not well-detailed
in large secondary retrospective analyses (eg, the
Highly Effective Reperfusion Evaluated in Multiple
Endovascular Stroke Trials [HERMES] Collaboration
cohort). In addition, intraprocedural hemodynamic
management was neither well-described nor reported
in detail in the cohort studies.21 In contrast, in the ran-
domized controlled anesthesia trials, control of hemo-
dynamic parameters adhered strictly to Society for
Neuroscience in Anesthesia and Critical Care (SNACC)
guidelines25,26 (SBP >140 mm Hg for both general anes-
thesia [GA] and sedation groups).27,28 These 2 points
highlight the impact of strict blood pressure goals
and aggressive management in attaining those goals
throughout the procedure (Table 5). Finally, in all 4
randomized trials (ie, Sedation versus Intubation for
Endovascular Stroke Treatment [SIESTA], Anesthesia
during Stroke [AnStroke], General or Local Anesthesia
in Intra Arterial Therapy [GOLIATH], Choice of
ANesthesia for EndoVAScular Treatment of Acute
Ischemic Stroke [CANVAS] Pilot), the care of patients
undergoing mechanical thrombectomy consisted of
highly protocolized management implemented by
specialized anesthesia teams. All these variables may
have contributed to the differences between the gen-
eral anesthesia and procedural sedation groups when
the cohort and randomized trials are compared.
Exclusion criteria and crossover between groups
may also have affected the results of randomized trials.
On analysis of pooled patient data from the randomized
controlled trials, a conversion rate of 11.5% from those
originally randomized to procedural sedation to gen-
eral anesthesia was observed. Severe agitation (43%)
was the most common reason for emergent conversion
followed by direct puncture of the common carotid
artery (19%), aspiration and respiratory insufficiency
(~10%). Patients who required conversion to general
anesthesia on an emergent basis did not have better
outcomes, possibly because of comorbidities, more
severe cerebral ischemia, a delay in reperfusion due to
the time needed to convert to GA, and hemodynamic
derangements associated with anesthetic induction.
Excluding the GOLIATH trial,24 all of the randomized
trials used severe agitation at presentation as part of
their exclusion criteria. Moreover, any patient pre-
senting with a depressed neurologic status—defined
as Glasgow coma scale/score (GCS) <8 in SIESTA29
and CANVAS,28 or GCS <9 in GOLIATH(20)—were
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 Stroke and Mechanical Thrombectomy

Table 3.  Anesthetic-Sedative Regimen Approach Table 4.  Common Complications in Acute Ischemic

and Mean Blood Pressure Levels During the Stroke Patients (Postalteplase, Postthrombectomy,
Mechanical Thrombectomy Procedures in the and Medical Management Only)31,32,33
Recent Randomized Anesthesia Trials27 Neurologic
Conscious Sedation General Anesthesia • Hemorrhagic transformation
Study Group Group • Reocclusion
SIESTA29 • Vascular injury (eg, vasospasm, perforation, dissection)
Anesthetic/sedative Propofol Propofol • Cerebral edema and elevated intracranial pressure
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14 ± 14 µg/kg/min, 49 ± 15 µg/kg/min, • Seizures

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remifentanil 0.03 ± remifentanil 0.1 Cardiovascular

0.03 µg/kg/min ± 0.06 µg/kg/min • Malignant hypertension and blood pressure variability
SBP (mm Hg) 148 ± 15 144 ± 17 • Arrhythmias
MAP (mm Hg) 104 ± 10 100 ± 11 • Cardiac ischemic events
• Cardiogenic shock
AnStroke22 Respiratory
Anesthetic/sedative Remifentanil Sevoflurane • Hypoxia (eg, apnea, aspiration, neurogenic, or cardiogenic pulmonary
(TCI 1.3 0.7 (0.6–0.7) MAC, edema)
[1.0–1.7] ng/mL) remifentanil • Loss of airway reflexes
(TCI 6 [5–6] ng/mL) Hematologic
SBP (mm Hg) 147 ± 17 141 ± 14 • Arterial access site complications (eg, bleeding, hematoma,
MAP (mm Hg) 95 ± 11 91 ± 8 pseudoaneurysm)
Other
GOLIATH24 • Hyperglycemia
Anesthetic/sedative Propofol Propofol • Temperature dysregulation
35 ± 33 µg/kg/min 56 ± 29 µg/kg/min
• Contrast allergy
Fentanyl Remifentanil
0.9 ± 0.5 µg/kg 0.26 ± 0.13 µg/kg/min
SBP (mm Hg) 155 ± 20 143 ± 15
MAP (mm Hg) 101 ± 12 95 ± 8 outcomes and mortality between general anesthesia
and monitored anesthesia care approaches.28
CANVAS Pilot28
Anesthetic/sedativea Sufentanil Sufentanil
Whether choice of agents used during general
0.1 µg/kg IV bolus 0.2 µg/kg IV bolus anesthesia or monitored anesthesia care affects out-
Propofol Propofol come is also unclear. In the reported randomized
(TCI 0.5–1 µg/mL) (TCI 1: 4 µg/mL) trials, variations of propofol and remifentanil were
Remifentanil
0.1–0.2 µg/kg/min most commonly used (Table 3). However, the 2017
SBP (mm Hg)b 148 ± 33 123 ± 21 AnStroke trial used sevoflurane for its general anes-
MAP (mm Hg)b 108 ± 25 89 ± 18 thesia group,22 2018 GOLIATH trial used fentanyl
Abbreviations: AnStroke, Anesthesia during Stroke; BP, blood pressure; for the conscious sedation group,24 and the 2020
CANVAS, Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic
Stroke; GOLIATH, General or Local Anesthesia in Intra Arterial Therapy; IV, CANVAS pilot trial used sufentanil for its sedation
intravenous; MAC, monitored anesthesia care; MAP, mean arterial pressure group.28 Regardless of anesthetic agent, doses of these
(ie, mean blood pressure); SBP, systolic blood pressure; SIESTA, Sedation
versus Intubation for Endovascular Stroke Treatment; TCI, target-controlled medications were uncharacteristically low compara-
infusion. tive to typical doses used for both conscious seda-
a
Anesthestic/sedative values given for the CANVAS trial report the doses
aimed to be used in the trial. Actual dose range for these medicines is not
tion and general anesthesia in different circumstances
reported yet. (Table 3).
b
BP values reported were from 10 min after the arterial puncture. They do not
represent a mean value of the whole intraprocedural period.
Although current evidence is frustratingly mixed,
it is likely that aspects of mechanical thrombectomy
excluded. As previously noted, the leading reason for such as time to recanalization, workflow consider-
failure of sedation and conversion to general anesthe- ations, and blood pressure control are more important
sia was severe agitation. Predicting which patients than the anesthetic technique per se. Initial enthusi-
are likely to progress to severe agitation further high- asm for monitored anesthesia care has been tempered
lights the importance of preprocedural evaluation and with recent randomized trials’ data. Anesthesiologists
patient selection in determining the anesthetic plan. can now implement general anesthesia with less of
Two 2019 metaanalyses concluded similarly that a concern for causing detrimental effects on patient
among patients undergoing anterior circulation outcome. Ultimately, the best answer will likely result
thrombectomy, those who received general anesthe- from individualized care, which accounts for the
sia compared to conscious sedation had less disability clinical characteristics of each patient, the location of
at 3 months and more functional independence.23,30 stroke, difficulty of general or monitored anesthesia
In addition, general anesthesia was also associated care, and difficulty of the procedure.3 Regardless of
with higher rates of successful recanalization.30 More the chosen anesthetic plan, strict adherence to intra-
recently, a fourth small single-centered randomized procedural blood pressure management with SBP
controlled trial reported no difference in functional goals >140 mm Hg remains important25,26 (Table 4).

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 EE Narrative Review Article
TRIAGE OF AIS PATIENT—FOR POSTALTEPLASE,
POSTTHROMBECTOMY, AND MEDICAL
MANAGEMENT ONLY
Care of the AIS patient ideally involves a multispe-
cialty comprehensive care team. The physical location
where a stroke patient is admitted is dependent on
both system and patient factors.
Patients presenting with AIS generally fall into
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3 therapeutic groups: those receiving IV alteplase
(tPA) only, those receiving mechanical thrombectomy
(with or without tPA), and those receiving medical
management without the aforementioned therapies.
Monitoring requirements for these patient groups are
described in current guidelines, but the intensity of
monitoring dictates the optimal location for postint-
ervention care. Automatic monitoring of physiologic
parameters is uniformly recommended. For example,
the European Stroke Organization (ESO) recommends
continuous electrocardiogram (ECG) recording in
patients with AIS and transient ischemic attacks.34 In
addition, the ESO reinforces 72 hours of monitoring
in patients with significant persisting neurologic defi-
cits, specifically including neurological status (repeat
examinations), pulse, blood pressure, temperature,
and oxygen saturation.34 Although these assess-
ments should be performed every 4 hours at a mini-
mum, most institutions use more frequent intervals.
Following IV alteplase, guidelines from the AHA/
ASA recommend strict blood pressure monitoring
intervals that require no less than hourly checks for
the first 24 hours, and more frequently in the first 6
hours of it.35,36 Following mechanical thrombectomy,
the Society of Neurointerventional Surgery (SNIS)
defined recommendations related to blood pressure
management for at least 24 hours—these specific goals
often require continuous hemodynamic monitoring.33
To most effectively achieve clinical goals, patients
receiving therapies for AIS should be admitted to a
specialized stroke unit, which in most hospitals is a
hybrid ICU/floor unit able to care for patients with
varying levels of acuity. If ICU beds are included in a
stroke unit, then a dedicated intensivist should lead
the primary care team. The most thorough recommen-
dations for the makeup of a stroke unit come from the
ESO. These include a geographically defined area or
ward, a multiprofessional team (ie, medical, nursing,
and therapy staff with specialty training and expertise
in stroke care), and comprehensive stroke care pro-
tocols that include not only diagnostic workup and
treatment but also early mobilization, rehabilitation,
and secondary prevention.37 Strong recommendations
for specialized stroke care via stroke units are echoed
by the AHA/ASA, ESO, and SNIS.3,33,34
Multiple clinical trials and systematic reviews
support stroke unit recommendations.38–42 A 2013
Cochrane review found that specialized stroke unit
October 2020 • Volume 131 • Number 4
Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
care resulted in improved survival, a higher prob-
ability of regaining independence and a higher
probability of returning home.40 A more recent 2015
retrospective cohort study compared traditional ICU
care with a mobile stroke team to a stroke unit and
found that the stroke care model had a lower prob-
ability of unfavorable outcomes (ie, death and depen-
dency) at 3 months.38 The mechanisms of underlying
improved outcomes with organized stroke care are
incompletely understood, but better continuity of
care by the primary neurology team, a harmonized
neurorehab program, comprehensive nursing proto-
cols and treatment algorithms, and familiarity with
stroke patients are all potential explanations.38
Both evidence-based and hospital-specific indica-
tions for ICU care need to be considered when triag-
ing a patient with an AIS.31 Complications following
AIS (Table 4)—particularly after IV alteplase (tPA)
or thrombectomy—have been outlined in the litera-
ture,3,31–33 and recent studies have added insight into
the acute stroke patient who may require and benefit
from critical care resources.43–46 The decision where
to admit the AIS patient requires balanced consider-
ations of patient factors, hospital system design and
resources, and major society guidelines.
PERIOPERATIVE STROKE
Stroke can be a devastating outcome for surgical
patients. The incidence of perioperative stroke after
noncardiac surgery approaches 2%–3% for high-risk
patients47,48 and is higher in patients undergoing car-
diac and major vascular surgery.49,50 Recent obser-
vational data suggest that incidence is increasing.51
Furthermore, clinically silent (ie, covert) stroke occurs
with a startling 7% incidence in noncardiac surgery
patients ≥65 years of age.52 Perioperative stroke is
also associated with delayed recognition, infrequent
thrombolysis, and high rates of death and disabil-
ity.53,54 As such, advancing our understanding of peri-
operative stroke and improving clinical management
strategies is an important research area.
Screening and Diagnosis
Identifying stroke in the early postoperative setting
is fundamentally challenging. The postoperative
environment can obfuscate neurologic assessment, as
residual anesthesia, opioid administration, pain, and
postoperative cognitive impairment can confound
physical examination findings. A 2019 prospective
cohort study observed that >30% of high-risk surgical
patients without acute stroke demonstrated changes
in modified National Institute of Health Stroke Scale
(mNIHSS) scores over the first 3 postoperative days.55
Stroke scales thus are likely to have a low positive pre-
dictive value in postoperative patients. A candidate
strategy for identifying clinically and therapeutically
www.anesthesia-analgesia.org 1129
 Stroke and Mechanical Thrombectomy
relevant stroke may instead be to focus screening
efforts on LVO. Signs of hemiparesis, gross sensory
deficits, and aphasia would reflect such pathology.
Currently recognized biomarkers are likely not to
be helpful. Levels of S-100β, neuron-specific enolase,
matrix metalloproteinase-9, and glial fibrillary acid
protein do not accurately identify a patient with intra-
operative hypoxic-ischemic injury,55 and levels fluctu-
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ate over orders of magnitude in the absence of overt
stroke. These findings cast doubt on the validity of
existing biomarkers. Assessing for specific changes in
neurophysiology (eg, electroencephalographic slow-
wave activity, oscillatory asymmetry) may aid in the
detection of cerebral ischemia.56–58 Such neurophysi-
ologic evaluation may thus represent an additional,
complementary strategy for detecting cerebral isch-
emia without neuroimaging, which can be cumber-
some and logistically challenging perioperatively.
Such neurophysiologic testing strategies await trans-
lation and validation in the perioperative setting.
Prevention
Novel evidence-based prevention strategies have been
suggested and may help to reduce the incidence of
postoperative stroke. In a large 2014 cohort study, the
adjusted odds for recurrent postoperative stroke were
increased throughout multiple postoperative time peri-
ods, with a dramatically higher risk within 3 months of
a prior stroke (odds ratio [OR] 67.60, 95% confidence
interval [CI], 52.27–87.42). Postoperative stroke risk did
not stabilize until approximately 9 months after a prior
index stroke. Delaying elective surgery for 9 months
after a stroke may reduce the likelihood of a second
stroke during surgery and has been endorsed by the
American College of Surgeons.59 Intraoperatively, the
combination of hypotension, hemorrhage, and beta-
blockade increases the risk of stroke.60 A 2013 propen-
sity-matched review found that stroke risk increased
incrementally in patients receiving perioperative beta-
blockade with a decrease in hemoglobin due to intra-
operative hemorrhage.60 Overall, adjusted stroke risk
was lowest for patients on bisoprolol, a cardioselective
beta-blocker. Adopting a higher transfusion threshold
for patients receiving beta-blocker therapy—particu-
larly noncardioselective agents—may reduce stroke
risk. Finally, updated perioperative anticoagulation
guidelines recommend deferring bridging therapy for
low-moderate risk surgical patients and shortening
the interruption window for newer, direct oral antico-
agulants.59,61,62 Following this strategy may minimize
stroke risk while also reducing the risk of major peri-
operative hemorrhage.63,64
Perioperative Stroke: Bottom Line
Perioperative stroke is associated with considerable
morbidity and mortality, and the incidence is both
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Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
underappreciated and increasing. Key areas for future
investigation should focus on improved screening
and diagnostic techniques. While physical examina-
tion findings may have limited specificity for detect-
ing cerebral ischemia, a targeted screening system for
LVO (eg, middle cerebral artery syndrome) and asso-
ciated signs and symptoms may be valuable. Surgical
patients are potentially eligible for both mechanical
thrombectomy and thrombolysis with IV tPA. Such
interventions should be considered with a multidisci-
plinary team that includes neurology, the primary sur-
gical service, and neurointerventionalists. Guidelines
are also available to help assess intervention eligibil-
ity.15 Serum biomarkers may aid in the detection of
ischemic injury, though further clinical-translational
investigation is required for validation in the peri-
operative setting. Electroencephalography may also
serve as a novel, complementary method for detecting
large-vessel ischemia perioperatively because isch-
emic changes are reflected by asymmetric oscillatory
patterns.56 Recently proposed prevention strategies
include delaying elective cases after a recent stroke,
adopting higher transfusion thresholds for patients
on perioperative beta-blocker therapy, and following
updated anticoagulation guidelines. Addressing key
knowledge gaps and improving clinical management
is both timely and imperative, and anesthesiologists
are well positioned to lead these efforts.
SUMMARY: ANESTHESIOLOGISTS’ IMPACT IN AIS
MANAGEMENT
Stroke is a medical emergency. Each minute of the
door-to-needle time for IV tPA therapy is critically
important to maximize the chance of favorable long-
term neurological outcome. In patients with strokes
due to LVO, minimizing door-to-groin puncture time
for mechanical thrombectomy and recanalization is
paramount. Although the time window for poten-
tial benefit from thrombectomy is currently 16–24
hours,17,18 each hour of delay in recanalization dimin-
ishes the chances of a good outcome.
Anesthesia and critical care anesthesia providers
may impact stroke outcomes at multiple levels of
care in many different acute care settings such as ER,
IR suite, ICU, and operating room (Figure). As anes-
thesiologists, we can increase the likelihood of good
functional outcome of our stroke patients by safely
securing the airway and managing blood pressure.25,26
Properly managed anesthesia can allow the interven-
tionalist to start recanalization procedures quickly and
safely. As critical care anesthesiologists, we can guide
the safe triage of stroke patients depending on the
level of care required, maintain their hemodynamic
stability, preserve normothermia and normoglyce-
mia, optimize oxygenation, preserve airway patency,
prevent hospital-acquired infections, and orchestrate
ANESTHESIA & ANALGESIA
 EE Narrative Review Article
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the multidisciplinary cooperation needed to optimize
long-term functional outcomes.3,4,26,27,40,65–69
With respect to anesthesia for thrombectomy,
large metaanalyses report worse outcomes with
general anesthesia compared to sedation retrospec-
tively.21 However, the most recent evidence from the
few recent prospective randomized controlled trials
indicates that protocol-based general anesthesia is
Table 5.  Management of Blood Pressure in
Acute Ischemic Stroke Requiring Mechanical
Thrombectomy69,77
Initial Management
• BP levels up to 220/120 mm Hg permitted to allow perfusion to
ischemic site3
• BP needs to be lowered to <185/110 mmHg for the tPA and MT
candidates3
• Hypotension worsens outcomes
◦ BP drops up to 15% considered within safety limits2
◦ SBP drop of >50 and acute SBP drop >30 mm Hg may worsen
functional outcomes71
◦ SBP <110 mm Hg is associated with increased mortality72
Revascularization Procedure (Mechanical Thrombectomy)
• Maintain SBP 140–180 mm Hg during the procedure26
• MAP ≥70 mm Hg at all times26
• Maximum up to 40% of drop in BP to be allowed for hypertensive
patients
Postcanalization
• If successful reperfusion (TICI 2b/3) maintain SBP <160 mm Hg,
but if any subsequent intracerebral hemorrhage, maintain
SBP <140 mm Hg18,73,74
• MAP >70 mm Hg associates with better functional outcomes75
• In case of incomplete reperfusion (TICI 0–2a), maintain BP
<180/105 mm Hg for at least 24 h3
• Induced hypertension can be considered for incomplete reperfusion
patients
• If there’s any end-organ hypoperfusion signs or change in neurologic
examination, you may consider maintaining BP at a higher range
Abbreviations: BP, blood pressure; MAP, mean arterial blood pressure; MT,
mechanical thrombectomy; SBP, systolic blood pressure; TICI, thrombolysis
in cerebral infarction scale; tPA, tissue plasminogen activator.
October 2020 • Volume 131 • Number 4
Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Figure. Multidisciplinary Stroke
Care-Anesthesia Team’s involve-
ment with the care continuum.
ER indicates emergency room;
ICU, intensive care unit; IR,
interventional radiology; LVO,
large-vessel occlusion; OT, occu-
pational therapy; PT, physical
therapy; tPA, tissue plasmino-
gen activator.
equivalent to procedural sedation and may even be
better for 3-month functional outcomes.23 It is likely
that time to recanalization, attention to blood pressure
management,70 (Table 5) and a coordinated care con-
tinuum are more important than the type of anesthe-
sia per se.
Anesthesia care providers need to be aware of peri-
operative stroke or covert stroke.54,76 Especially for
elderly patients and during emergency procedures, car-
diovascular procedures, cases with prolonged hemo-
dynamic compromise, extensive bleeding situations,
and in patients with history of recent strokes, the risk of
perioperative stroke increases significantly. Identifying
patients at high risk, concentrating on differential diag-
noses, and reviewing the shortlist of reasons of post-
operative delayed emergence may contribute to the
outcomes of this devastating clinical phenomenon.
In this review, we summarize the importance of
anesthesia and critical care professionals’ roles in AIS
care and the impact of this safe care continuum in
patient’s long-term functional outcomes. Our focus
on patient-centered care and emphasis on safe hand-
offs between different care environments will evolve
our key contributor role in the multidisciplinary care
continuum of stroke. E
DISCLOSURES
Name: Jerrad Businger, DO.
Contribution: This author has helped with the planning of this
narrative review article. He also has written the “Anesthetic
Management of Mechanical Thrombectomy” section.
Additionally, he contributed to the whole text flow and visuals
of this review.
Name: Alexander C. Fort, MD.
Contribution: This author has helped with the planning of this
narrative review article. He also has written the “Triage of AIS
www.anesthesia-analgesia.org 1131
 Stroke and Mechanical Thrombectomy
Patient—For Postalteplase, Postthrombectomy, and Medical
Management Only” section. Additionally, he contributed to the
whole text flow of this review.
Name: Phillip E. Vlisides, MD.
Contribution: This author has helped with the planning of this
narrative review article. He also has written the “Perioperative
Stroke” section. Additionally, he contributed to the whole text
flow of this review.
Name: Miguel Cobas, MD, FCCM.
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Contribution: This author has helped with the planning and
structure of this narrative review article. He also has written the
“Acute Management of Ischemic Stroke” section. Additionally,
he reviewed the manuscript in full and assessed the text flow
of this review.
Name: Ozan Akca, MD, FCCM.
Contribution: This author has helped with the planning and
structure of this narrative review article. He also has written
the “Introduction” and “Summary: Anesthesiologists’ Impact
in AIS Management” sections. Additionally, he reviewed the
manuscript in full, assessed the text flow, and contributed to
the visuals of this review.
This manuscript was handled by: Avery C. Tung, MD.
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