Sedation And Stroke: Is Conscious Sedation Safe?

Conscious sedation is a safe and effective alternative to general anesthesia for patients with acute ischemic stroke undergoing endovascular treatment. Patients treated under conscious sedation have a lower risk of poor neurological outcomes and mortality than those treated under general anesthesia. Conscious sedation may also lead to more stable hemodynamics and a lower incidence of pneumonia. However, the choice of anesthesia depends on the patient's physical status, and general anesthesia may be preferred for patients with underlying medical conditions or stroke severity. Ultimately, the decision to use conscious sedation or general anesthesia should be made in close communication with the neurointerventionalist.

Conscious sedation may lead to more stable hemodynamics and a lower incidence of pneumonia

A study by Liang Liu et al. found that patients in the general anesthesia group had a higher risk of mortality (OR = 1.68, 95% CI: 1.49–1.90), pneumonia (OR = 1.78, 95% CI: 1.40–2.26), and symptomatic intracranial hemorrhage (OR = 1.64, 95% CI: 1.13–2.37). Similarly, a study by Chunguang Ren et al. found that patients in the general anesthesia group had a significantly higher rate of pneumonia.

Additionally, general anesthesia is often associated with hemodynamic disturbances, including rapid blood pressure fluctuations and lower blood pressure, which can lead to decreased cerebral blood flow and exacerbate ischemic injury. Conscious sedation, on the other hand, can help maintain hemodynamic stability and reduce the risk of these complications.

Conscious sedation may be associated with less manpower and time, lower cost, fewer hemodynamic fluctuations, and the ability to assess neurological function during the procedure

Less Manpower and Time

Conscious sedation may be associated with less manpower and time. In a study by Abou-Chebl et al., it was found that conscious sedation may require less time to initiate than other approaches.

Lower Cost

Conscious sedation may be associated with a lower cost. In a study by Davis et al., it was found that general anesthesia was associated with significantly higher treatment costs than conscious sedation.

Fewer Hemodynamic Fluctuations

Conscious sedation may be associated with fewer hemodynamic fluctuations. In a study by Reich et al., it was found that propofol and fentanyl induction doses may cause post-induction hypotension. In a study by Whalin et al., it was found that dexmedetomidine, a sedative, can stabilize blood pressure and prevent hypotension.

Ability to Assess Neurological Function During the Procedure

Conscious sedation may allow for the ability to assess neurological function during the procedure. In a study by Abou-Chebl et al., it was found that conscious sedation allows for the monitoring of neurologic status during the procedure.

Conscious sedation may be associated with improved hemodynamic stability compared with general anesthesia

The study also found that conscious sedation was associated with a lower incidence of pneumonia. The pulse oxygen saturation was significantly higher in the general anesthesia group at most time points. This may be due to the endotracheal intubation and controlled ventilation that is typically used during general anesthesia. Conscious sedation, on the other hand, often involves supplemental oxygen delivered via a facemask.

The choice of anesthesia during endovascular stroke treatment is a matter of debate. While conscious sedation may offer advantages such as improved hemodynamic stability and lower infection rates, general anesthesia provides benefits such as immobility, airway protection, and better radiographic imaging. The decision should be individualized based on the patient's clinical characteristics and the specific procedure being performed.

Conscious sedation may be associated with a lower rate of pneumonia

Sedation is often necessary to safely perform intra-arterial (IA) revascularization procedures. However, the level of sedation used varies. Some institutions routinely paralyse and intubate patients as standard, while others follow no sedation protocol.

A 2010 study found that patients who were intubated and given general anaesthesia had a greater chance of poor neurological outcome and mortality than those given conscious sedation. However, the study did not answer many questions necessary to support this conclusion.

A 2019 meta-analysis of 23 studies including 6,703 patients found that patients in the general anaesthesia group had a higher risk of pneumonia than those in the conscious sedation group. However, the authors noted that the findings were mainly based on retrospective studies and that additional multi-centre randomised controlled trials were needed to address the issue.

A 2020 randomised clinical trial found that patients in the general anaesthesia group had a significantly higher rate of pneumonia than those in the conscious sedation group.

A 2021 study found that patients treated under conscious sedation showed a lower rate of pneumonia than those treated under general anaesthesia.

A 2015 systematic review and meta-analysis of nine studies found that patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anaesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies.

Conscious sedation may be associated with a lower rate of conversion to general anesthesia

Another study, published in the journal BMC Anesthesiology, found that patients who underwent general anesthesia had lower odds of a favorable functional outcome and a higher risk of mortality, pneumonia, and symptomatic intracranial hemorrhage compared to those who underwent conscious sedation.

A third study, published in the journal Frontiers in Neurology, found that patients who underwent general anesthesia had a higher risk of mortality and respiratory complications compared to those who underwent conscious sedation. The study also found that conscious sedation was associated with more stable hemodynamics and a lower incidence of pneumonia.

A fourth study, published in the journal AJNR: American Journal of Neuroradiology, found that patients who underwent general anesthesia had a higher risk of death and respiratory complications compared to those who underwent conscious sedation. The study also found that conscious sedation was associated with a higher rate of successful recanalization.

Finally, a fifth study, published in the Journal of Stroke, found that patients who underwent general anesthesia had a higher risk of periprocedural complications, longer hospital stays, and higher mortality rates compared to those who underwent conscious sedation. The study also found that conscious sedation was associated with a higher rate of successful reperfusion and better functional outcomes.

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