Failure of local anaesthesia for mechanical thrombectomy after anterior circulation acute ischaemic stroke

Mechanical thrombectomy (MT) has become the gold standard in the treatment of anterior circulation acute ischemic stroke (internal carotid, middle cerebral artery Ml, proximal anterior cerebral artery). The anaesthetic strategy for MT, including local anaesthesia associated or not with conscious sedation (LA/CS) and general anaesthesia (GA), remains an important subject of controversy. Many observational studies hove shown an unfavourable evolution of patients treated under GA, possibly due to the haemodynamic consequences of GA. In the absence of a formal indication for GA, it seems reasonable to prefer LA/CS in patients with similar characteristics to those included in studies that have validated MT. However, studies evaluating anaesthesia for MT include a significant selection bias, with severe patients often treated under GA, and three recent monocentric randomised studies did not found any difference in terms of functional outcome or growth in the size of the infarction. In this case, the failure of LA/CS due to significant agitation required emergency GA conversion with rapid sequence induction and use of relatively high doses of anaesthetics that induced hypotension. GA prevents such a conversion and should be discussed for patients at risk of LA/CS failure. In the case of GA, the use of anaesthetic agents that can induce hypotension should be anticipated by the initiation of a vasopressor infusion, the doses of which will be adapted to the patient's haemodynamic state during the procedure.