Anesthesia Considerations in Older Adults Undergoing Emergency Mechanical Thrombectomy for Acute Ischaemic Stroke

Abstract

Acute ischemic stroke (AIS) is a significant cause of morbidity and mortality among older adults, with its incidence, severity, and complication rates increasing with age. Endovascular thrombectomy (EVT) is the standard treatment for AIS due to a large vessel occlusion (LVO), but many landmark trials have excluded patients aged 80 years and older, resulting in a gap in the available evidence. Nonetheless, meaningful recovery is possible when successful recanalization is achieved, especially in patients with good pre-stroke functionality. When making EVT decisions for older adults, it is crucial to consider the unique challenges presented by this population. These challenges include age-related vascular changes, comorbidities, declining organ function, polypharmacy, altered drug responses, frailty, and baseline cognitive impairment. Anesthesiologists play a crucial role in optimizing outcomes through rapid assessment, careful physiological management, and effective multidisciplinary coordination. Both general anesthesia (GA) and conscious sedation (CS) are valid options for EVT, with the choice depending on patient factors, the complexity of the procedure, and the expertise of the institution. While GA may enhance recanalization rates and improve outcomes, it also carries increased risks such as delayed time from door to groin, hypotension, and a higher incidence of postoperative delirium and pneumonia. In contrast, CS may offer a safer alternative in selected cases, although it can limit the effectiveness of the procedure, potentially impacting reperfusion success. The impact of specific anesthetic agents on outcomes for older patients is still unclear. In addition, age-related changes in cardiovascular, respiratory, renal, and neurological functions, along with polypharmacy, contribute to an increased risk of hemodynamic instability and drug interactions. Older patients also face a higher risk of perioperative complications, such as delirium and cognitive dysfunction, which complicate the management of anesthesia. However, anesthesiologists can positively influence outcomes by managing modifiable factors such as, maintaining blood pressure within guideline-based targets, keeping blood glucose levels between 140 and 200 mg/dL, ensuring normoxia and normocapnia, avoiding hyperthermia, and anticipating technical challenges posed by tortuous, atherosclerotic vessels and resistant clots. This review aims to thoroughly examine anesthesia management for EVT in older adults.