The American Stroke Association is a division of the American Heart Association.
In the study, the procedure – called intracranial (within the skull) angioplasty – was safely performed on 10 patients who were given local anesthesia with mild sedation, rather than the general anesthesia that is traditionally administered. Local anesthesia is injected near the access area to block pain impulses; general anesthesia induces a complete loss of consciousness.
"This appears to be a clever approach for the elective patient who is in relatively good health," says senior study author Alex Abou-Chebl, M.D., an interventional neurologist in the section of stroke and neurological critical care at the Cleveland Clinic in Cleveland, Ohio. "It makes a lot of sense that having this information allows doctors to intervene and prevent worse outcomes."
However, he also cautions that a randomized controlled study in which local and general anesthesia are compared head to head in larger numbers of patients is needed to confirm these findings.
Abou-Chebl credits senior author Jay S. Yadav, M.D., director of vascular intervention at the Cleveland Clinic, with bringing the procedure to the neurology unit.
"Dr. Yadav has been doing heart angioplasties on awake patients for years, so he's adept at handling any emergency situation that can arise during the procedure," Abou-Chebl explains. "He took the procedure from cardiology and transferred it to the brain."
In angioplasty, a tiny balloon is threaded into the area of blockage and inflated. As the balloon expands, it forces the fatty plaque against the arterial wall, opening the vessel. Balloon angioplasty is widely used to open blocked heart arteries but is not commonly used for clearing neck and brain arteries. Cracking open a blockage can injure the blood vessel wall, which, in the case of intracranial angioplasty, can cause bleeding in the brain – a hemorrhagic stroke.
In some cases, a miniature wire coil known as a stent is left behind after angioplasty to keep the artery propped open. This further increases the chance of complications, explains Derk W. Krieger, M.D., Ph.D., a staff physician in the section of stroke and neurocritical care at the Cleveland Clinic and a member of the study team.
Stents offer benefits, but they also can jab against the walls of the blood vessels, causing fatty debris to break off and enter the bloodstream. If the debris travels to and lodges in a blood vessel, the result can be an ischemic stroke (caused by blockage) or a short-term blockage of blood flow known as a transient ischemic attack (TIA).
The interventional neurology team reasoned that performing the angioplasty under local anesthesia would afford the opportunity to monitor the patient's neurological status during the procedure. Then they could adjust the technique if needed, minimizing the risk of such complications.
In the study, angioplasty with or without stenting was used to open 11 clogged brain blood vessels in 10 patients who had failed to respond to the best available medication.
"Since the patient was awake, he could tell us about any unusual symptoms such as numbness or pain behind the eye that are signs of impending complications," Abou-Chebl says. "If the patient felt a sudden painful sensation behind the eye, for example, that told us we're over-stretching the vessel with the balloon. So we would immediately deflate the balloon, minimizing the damage."
All 11 procedures were technically successful, the study showed, but there were three complications related to the angioplasty and/or stenting. In one case, the stent blocked a small artery at the base of the skull. In two cases, there was minor bleeding in the brain. "But in all three cases, the neurological assessment heralded the complication and helped guide therapy," Abou-Chebl says.
The doctors immediately stopped inflating the balloon and attempted to bring the patients' blood pressure under control. Two patients fared well, and one died.
Overall, the results are encouraging and indicate the strategy is worth pursuing, Abou-Chebl says. But, he adds, local anesthesia is not for everyone – only for the stable patient with blocked arteries undergoing elective angioplasty to open up clogged neck and brain arteries.
For patients who have already had a stroke, who need a tube to help them breathe or who are otherwise unstable, general anesthesia is indicated. It produces better images and is associated with a smoother procedure.
The other author is Christopher Bajzer, M.D. This study was funded by the Cleveland Clinic.
Abstract P310
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