Neurocritical Care Support of Endovascular Mechanical Thrombectomy

doi:10.21203/rs.3.rs-4986970/v1

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Research Article

Neurocritical Care Support of Endovascular Mechanical Thrombectomy

https://doi.org/10.21203/rs.3.rs-4986970/v1

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Background

Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality, where timely intervention with mechanical thrombectomy (MT) is crucial for restoring cerebral blood flow and improving patient outcomes. This study evaluates the impact of a dedicated Neurocritical Care Rapid Response Team (NCC-RRT) on MT workflow efficiency and patient outcomes.

Methods

We conducted a prospective analysis of AIS patients undergoing MT at a Comprehensive Stroke Center between January 2021 and December 2023. The study compared two periods: Era 1 (pre-NCC-RRT, January-October 2021) and Era 2 (post-NCC-RRT, December 2021-December 2023). The NCC-RRT was responsible for the expedited transfer, airway management, procedural analgosedation, and hemodynamic support. Key metrics, including door-to-groin-puncture (DTGP) and door-to-recanalization (DTR) times, were analyzed.

Results

A total of 395 patients were included in the study. The implementation of the NCC-RRT significantly reduced DTGP and DTR times, particularly in patients receiving general anesthesia (GA). The NCC-RRT was associated with a 14.3% reduction in groin-puncture-to-recanalization time and a 26.6% increase in GA utilization. Additionally, significant time reductions were observed in both direct ED presentations and transferred patients.

Conclusions

The introduction of a dedicated NCC-RRT led to substantial improvements in MT process efficiency, highlighting the critical role of neurocritical care in optimizing stroke treatment and enhancing patient outcomes. This model offers an effective alternative for centers where dedicated neuroanesthesia teams are unavailable.

Acute Ischemic Stroke

Endovascular Thrombectomy

Analgosedation

hemodynamics

Neurocritical Care

Acute ischemic stroke (AIS) is a leading cause of long-term mortality and morbidity.[1] Impaired cerebral blood flow (CBF) downstream of the occlusion leads to rapid neuronal death at almost 2 million cells a minute.[2] Acute reperfusion therapies, including intravenous thrombolysis and increasingly endovascular mechanical thrombectomy (MT) in patients with medium and large vessel occlusion, can restore cerebral blood flow (CBF) to the ischemic but not yet infarcted brain tissue. “Time is brain,” and delays in MT are associated with worse patient outcomes [3, 4]. Efficient MT workflow expedites revascularization and improves outcomes [5]. Establishing collaborative teamwork among several disciplines involved in MT, including emergency department (ED), vascular neurology, neurointerventional radiology (NIR), and anesthesiology [6], can be challenging and limited by available institutional resources. The neurointensivists with expertise in brain physiology, analgosedation, and hemodynamics management are well-positioned to coordinate care and optimize MT care. In our institution, we established a dedicated neurocritical care rapid response team (NCC-RRT) to streamline the MT process and provide comprehensive medical support for AIS patients undergoing MT. The primary objective was to evaluate whether a dedicated NCC-RRT improves standard metrics in AIS treatment. Here, we present the impact of NCC-RRT on AIS treatment and outcomes.

This study was approved by the Institutional Review Board of Inova Fairfax Medical Center (IFMC), a designated Comprehensive Stroke Center in northern Virginia (Protocol# U22-06-4777).

Patients and Study Design

This study aimed to reduce care variation and enhance efficiency in MT by implementing a dedicated NCC-RRT pathway. Adult AIS patients who presented to the ED and underwent MT between 1 January 2021 to 31 December 2023 were tracked in a prospectively maintained stroke registry. We excluded inpatient AIS patients after admission due to low case numbers and different workflow. The study was divided into two periods: Era 1 (01/01/2021-10/30/2021) and Era 2 (12/01/2021-12/31/2023) before and after the introduction of the NCC-RRT, respectively; November 2021 was a transition period and excluded from the analysis.

Patient care was guided by the institutional stroke pathway. In brief, the vascular neurology team responded to the “stroke alerts” in the ED. During Era 1, the ED and NIR teams, with intermittent anesthesiologist support, managed airway, analgosedation, and hemodynamics support for AIS patients deemed eligible for MT. In November 2021, the NCC-RRT was introduced to take over care of all AIS patients undergoing MT. in Era 2, upon identification of MT-eligible patients, the new workflow concurrently notified the NCC-RRT and NIR physician and the NIR staff. The NCC-RRT consisted of neurocritical care providers (physician, advanced practice provider, and Neuro-Rapid-Response nurse), and respiratory therapist. The team was responsible for the expedited transfer, airway management, procedural analgosedation, and hemodynamic support in the ED, NIR suite, and post-MT care in the neurointensive care unit (Schematic Fig. 1).

Blood pressure targets before and after MT were determined and managed by the NCC-RRT. Prior to successful recanalization, defined as mTICI grade 2b or better, systolic blood pressure was maintained greater than 150 mmHg to 180 mmHg and 220 mmHg, for patients with or without IV thrombolysis, respectively. Thereafter, the blood pressure target was lowered based on the adequacy of recanalization. During Era 1, intubations were done for airway protection in the ED. In Era 2, NCC-RRT team determined the indication for intubation based on the need for airway protection, hemodynamic stability, neurological exam and ability to follow commands, and the cerebrovascular occlusion site (distal versus proximal). The intubations were performed in the NIR suite when feasible. Medications for blood pressure management, endotracheal intubation, and procedural analgosedation were left to the discretion of the NCC-RRT physician. In the majority of the cases, for induction, etomidate and ketamine were chosen due to their favorable hemodynamic properties [7]. Post-intubation analgosedation included ketamine, propofol and fentanyl infusions to maintain RASS − 4 to -5.

Statistical Analysis

Analysis was performed to determine the impact of NCC-RRT on process-related standard metrics for MT in AIS patients, such as door-to-groin-puncture (DTGP) and door-to-recanalization time (DTR), and patient outcomes, such as in-hospital mortality and discharge deposition. The results are stratified by transfer versus direct presentation to the ED. Categorical variables are reported as absolute numbers and percentages. Continuous variables are presented as mean and standard deviation (SD) or median and interquartile range (IQR). The Two-sample and paired t-tests were used to compare the numeric variables. The Mann-Whitney U test was used for time metrics due to non-normal distribution of the dataset. Statistical analyses were performed using SAS 9.4 (SAS Institute, Cary, NC). All analyses were two-tailed, and the significance level was determined by p < 0.05.

Between January 1, 2021, and December 31, 2023 (excluding November 2021), 395 patients with AIS underwent MT. Table 1 summarizes baseline patient characteristics.

Table 1

Baseline patient characteristics
Variable	Era 1 (1/1/21 − 10/31/21) N = 94	Era 2 (12/1/21 − 12/31/23) N = 301	p-Value
Age, mean ± SD	69 ± 16	70 ± 16	0.8267
Male, n (%)	55 (58.5%)	156 (51.8%)	0.2568
LOS, day	6 [ 4–11]	6 [ 4–11]	0.9975
Initial NIHSS	16 [ 11–23]	17 [ 10–22]	0.8088
Transfer (%)	46 (48.9%)	158 (52.5%)	0.5470
Received Thrombolytic, n (%)	26 (27.7%)	105 (34.9%)	0.1941
GA, n (%)	44 (46.8%)	221 (73.4%)	< .0001
GA in IR, n (%)	1 (1.1%)	95 (31.6%)	< .0001
Good TICI grade, n (%)	80 (85.1%)	277 (92.0%)	0.0470
Discharged to home, n (%)	29 (30.9%)	113 (37.5%)	0.2380
Mortality, n (%)	15 (16.0%)	24 (8.0%)	0.0235
All continuous data shown as mean ± SD or median and interquartile range (IQR). All proportions shown as number (%).
LOS, Length of stay; NIHSS, NIH Stroke Scale; GA, General anesthesia; CS, Conscious sedation; IR, Neuro IR suite; TICI, Thrombolysis in Cerebral Infarction.

With the implementation of dedicated NCC-RRT support, we observed significant reductions in several time performance metrics during Era 2 (Table 2 and Fig. 2A). In addition, the rate of procedural intubation in the NIR suite and the use of general anesthesia (GA) increased significantly in Era 2. However, there was no significant difference in the door-to-intubation time between the eras (Era 1: 41 minutes, IQR 19–70 vs. Era 2: 43 minutes, IQR 24-63.5; p = 0.9646). The DTGP and DTR times improved for both the GA and conscious sedation (CS) groups in Era 2, with more pronounced and statistically significant improvements in the GA group. The introduction of NCC-RRT resulted in an overall 14.3% reduction in groin-puncture-to-recanalization time in Era 2 (p = 0.0188), and this effect was also statistically significant within the GA or CS groups individually (p < 0.05) (see Table 2 and Fig. 2B).

Table 2

Comparison of time Metrics between Era 1 and Era 2
Variable	Era 1 (1/1/21 − 10/31/21) N = 94	Era 2 (12/1/21 − 12/31/23) N = 301	p-Value
D to IR suite	67.5 [32–99]	49 [16–81]	0.0010
D to intubation	41 [19–70]	43 [24–63.5]	0.9646
DTGP	82 [48–110]	71 [41–98]	0.0326
DTGP (GA)	91 [61–125.5]	77 [46–98]	0.0082
DTGP (CS)	69 [38–98]	48 [27–98.5]	0.0587
DTR	112 [79–149]	100 [66–128]	0.0046
DTR (GA)	132 [103–183]	106.5 [73.5–129.5]	0.0005
DTR (CS)	94 [71–126.5]	82.5 [55–116]	0.0393
GP to Recanalization	28 [19–51]	24 [18–38]	0.0188
GP to Recanalization (GA)	30 [20–59]	25 [18.5–39]	0.0418
GP to Recanalization (CS)	25.5 [19–43]	21 [17–31]	0.0451
All continuous data shown as median (min) and interquartile range (IQR).
DTGP, as door-to-groin-puncture; DTR, door-to-recanalization; GP, groin-puncture; GA, General anesthesia; CS, Conscious sedation.

Similar improvements were noted when stratifying data by direct presentation to the ED versus transferred patients. For direct ED presentations, we observed significant reductions in the door-to-NIR suite (p = 0.0038), DTGP (p = 0.0499), and DTR (p = 0.0332) times in Era 2, with greater improvements noted in GA patients (Table 3). Specifically, for direct ED presentations undergoing GA, the DTGP time decreased from 110 minutes (IQR 91–183) in Era 1 to 91 minutes (IQR 77–105) in Era 2 (p = 0.0011). Additionally, the DTR time for this subgroup decreased from 154 minutes (IQR 115–224) to 117 minutes (IQR 103.5–143) in Era 2 (p = 0.0032).

Table 3

Comparison of time metrics between Era 1 and Era 2 for ED cases
Variable	Era 1 (1/1/21 − 10/31/21) N = 48	Era 2 (12/1/21 − 12/31/23) N = 158	p-Value
D to IR suite	87.5 [ 67.5–113]	72 [57–91]	0.0038
D to intubation	48 [ 35–128]	53 [41–71]	0.9501
DTGP	98 [81.5–129.5]	91 [77–111]	0.0499
DTGP (GA)	110 [91–183]	91 [77–105]	0.0011
DTGP (CS)	94 [73–108]	101 [76–124]	0.5310
DTR	132 [107–183]	116 [100–144]	0.0332
DTR (GA)	154 [115–224]	117 [103.5–143]	0.0032
DTR (CS)	119 [94–146.5]	108.5 [92–148]	0.5276
GP to Recanalization	26 [18–47]	24 [18–34]	0.2801
GP to Recanalization) (GA)	26 [18–51]	25 [19–37.5]	0.5068
GP to Recanalization (CS)	25.5 [19.5–33.5]	19.5 [16–26]	0.0391
All continuous data shown as median (min) and interquartile range (IQR).
DTGP, as door-to-groin-puncture; DTR, door-to-recanalization; GP, groin-puncture; GA, General anesthesia; CS, Conscious sedation.

For transferred cases, there were also significant reductions in door-to-NIR suite, DTGP, and DTR times in Era 2 (p < 0.0001, p = 0.0251, and p = 0.0011, respectively), with a more substantial effect observed in GA patients (Table 4). The improvement in DTGP time was particularly notable for transferred patients in Era 2.

Table 4

Comparison of time metrics between Era 1 and Era 2 for transfer cases
Variable	Era1 (1/1/21 − 10/31/21) N = 46	Era 2 (12/1/21 − 12/31/23) N = 143	p-Value
D to IR suite	31 [22–67]	14 [5–36]	< .0001
D to intubation	97 [97–97]	51 [51–51]	0.8837
DTGP	46.5 [37–81]	40 [28–55]	0.0251
DTGP (GA)	60 [43–91]	43 [34–59]	0.0207
DTGP (CS)	38 [34–55]	31 [22–44]	0.0209
DTR	90 [67.5–131]	67.5 [53–94.5]	0.0011
DTR (GA)	114 [84–143.5]	70.5 [54.5–101.5]	0.0011
DTR (CS)	71.5 [59–103]	56 [49.5–88.5]	0.0263
GP to Recanalization	31.5 [21–59]	23 [17–40]	0.0331
GP to Recanalization (GA)	36 [22.5–73.5]	23.5 [17.5–41.5]	0.0378
GP to Recanalization (CS)	25 [18.5–48.5]	22 [17–39]	0.2722
All continuous data shown as median (min) and interquartile range (IQR). DTGP, door-to-groin-puncture; DTR, door-to-recanalization; GP, groin-puncture; GA, General anesthesia; CS, Conscious sedation.

Developing and refining multidisciplinary workflows for mechanical thrombectomy (MT) has been shown to reduce door-to-groin puncture (DGP) times and improve functional outcomes [5, 6, 8, 9]. Hemodynamic and analgosedation care is increasingly recognized as a critical aspect of the MT workflow, heavily dependent on the availability of anesthesia during MT [10]. In fact, the routine involvement of anesthesiologists during MT may improve workflow performance measures, including reduced DGP time [11]. Therefore, variability in anesthesiologist availability for MT, as is the case at some MT centers such as ours [12], can lead to inconsistencies in MT. Given the challenges of anesthesiologist availability, the NCC-RRT may serve as an alternative or additional resource to anesthesiology by providing consistent analgosedation and hemodynamic support. Our findings are relevant given the well-established association between these time metrics and patient outcomes.[13–16]

The impact of GA versus CS for mechanical thrombectomy remains unclear based on retrospective studies [17–20]. Three small randomized controlled trials suggest that recanalization time and patient outcomes are at least equivalent, if not improved, with GA [21–23]. Additionally, intra-procedural conversion from CS to GA may result in worse outcomes [24]. Lastly, GA is also associated with reduced fluoroscopy time [25]. In this study, the implementation of the NCC-RRT was associated with a significant 26.6% increase in the use of GA and a 30.5% increase in intubation in the NIR suite. The higher rate of GA by the NCC-RRT in this study likely reflects the preference and comfort for GA by both the NIR and NCC attending physicians, particularly in cases of distal vessel occlusions or the possibility of requiring extra- or intracranial arterial stenting during MT. Nonetheless, DTGP and DTR times improved in both GA and CS groups in Era 2. Furthermore, in Era 2, DTGP times for intubated patients were comparable to or faster than those for non-intubated patients, reversing the trend from Era 1. The only exception was after-hours transfers, where DTGP was faster for non-intubated patients. This likely resulted from fewer intubations in the IR suite during after-hours transfers (49% versus 73% during the day), as patients were held in the ED pending NIR team arrival, delaying DTGP times. This highlights the benefit of optimizing direct-to-NIR workflow.

GA can be associated with a more severe reduction in blood pressure as compared to CS [26]. Although optimal blood pressure may vary based on several patient factors, such as a history of hypertension and adequacy of brain collateral circulation, several studies have linked hypotension to worse outcomes in MT patients [27–29]. Consequently, the Society of Neuroanesthesia recommends maintaining systolic blood pressure between 140 and 180 mmHg during MT [30]. In clinical practice, however, blood pressure targets and the choice of analgesia and sedation agents, along with their associated hemodynamic effects, can vary widely. A recent multinational survey of anesthesiologists from more than 50 institutions shows that adherence to strict blood pressure guidelines is more commonly applied by neuroanesthesiologists than by general anesthesiologists [31]. Some authors recommend the routine involvement of anesthesiologists, particularly neuroanesthesiologists, during MT to avoid hypotension [32, 33]. While we agree with this concept, anesthesia support is not routinely available in almost a third of MT centers, according to a survey of 30 American institutions [12], with even fewer having dedicated neuroanesthesia teams [31]. Our proposed NCC-RRT, with expertise in managing the airway, analgesia and sedation, and hemodynamics of complex cerebrovascular patients, offers an alternative MT support model where neuroanesthesia is unavailable.

This study has several limitations. The findings are based on the experience of a single center, and although the study was prospective, patients were not randomized to receive care from the NCC-RRT versus the traditional care model. Additionally, stroke workflows are continuously evolving, and some improvements in key metrics may have occurred independently of the NCC-RRT. The sample size limits the ability to adequately analyze important subgroups, such as off-hours and transfer patients. Regarding the generalizability of our findings, neurocritical care teams do not perform endotracheal intubation or provide moderate to deep sedation in all institutions, making our results less applicable to other settings. Moreover, early involvement of the NCC-RRT could interfere with established workflows in the ED and NIR suite. Establishing an NCC-RRT may also require significant expansion of the neurocritical care team, which may not be clinically or financially justifiable for some centers.

The implementation of the Neurocritical Care-Rapid Response Team (NCC-RRT) led to substantial improvements in care delivery for stroke patients undergoing mechanical thrombectomy (MT). These findings underscore the value of dedicated neurocritical care teams in enhancing the efficiency of stroke treatment and potentially improving patient outcomes.

Acknowledgments

The authors would like to acknowledge the dedicated staff of the emergency department, neurointerventional radiology (NIR) suite, transfer center, EMS, ambulance transport, and neuroscience intensive care unit for their commitment and contributions to patient care. Special thanks to Yun Fang for providing the statistical analysis.

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Neurocritical Care Support of Endovascular Mechanical Thrombectomy

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Abstract

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Introduction

Methods

Patients and Study Design

Statistical Analysis

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Discussion

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Acknowledgments

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