Drs. Tarpley, Tietelbaum, Hou

CODE STROKE: Executive Summary for Anesthesiologists


General Considerations

  • The following applies to thrombotic (occlusive) stroke (not hemorrhagic)

  • Key metric: Safely achieve arrival to groin puncture time < 60 minutes

  • Code stroke will be called by cath lab to front desk or AIC during normal house, and house supervisor directly to the anesthesiologist after hours

  • Because anesthesia is requested primarily for maintaining BP goals, it will be up to the attending neuro-interventional radiologist if they want an anesthesiologist present

  • MAC vs GA is an ongoing discussion. There are at least 2 ongoing RCTs (ANSTOKE & GOLIATH) that will give us a clearer idea of whether GA causes bad outcomes, or whether GA is simply a marker for a sicker patient. What we clearly know is that acute thrombotic stroke patients present in a hyperdynamic state because their bodies are compensating for blunted cerebral autoregulation. They are at high risk for hypotension upon induction. This hypotension, even if transient, will make the disease process worse and increase morbidity/mortality. Therefore, when practical, we should avoid GA in favor of zero to minimal sedation. It will be up the anesthesiologist to favor MAC over GA. If they choose GA, they must be prepared to treat hypotension upon induction. Maintaining BP goals under GA can be burdensome during these cases and can require escalating pressor therapy. 

  • MAC is preferred by the radiologist but may not be suitable for all patients



  • Cath lab team will perform basic preop (NPO status, cardiopulmonary evaluation, allergies) and will consent patients for procedure and anesthesia simultaneously. Anesthesia consent is stapled to procedure consent and both forms will be signed.

  • Ideally, anesthesiologists would see the patient in ED, however, we do not want to be the reason for delaying groin puncture



  • Avoid radial a-line. They are difficult to place in the cath lab setting and can result in significant delay. If IABP monitoring is indicated, we can transduce off femoral sheath.

  • Because the procedure will not be delayed for anesthesia assessment/consent/arrival, monitors will be placed by cath lab team upon arrival to room if anesthesiologist is not yet present. This includes all monitors being placed away from head with cables running down left arm, nasal cannula with ETCO2 tubing, and proper placement of IV pole to avoid interference with C-arm. If GA, then long breathing circuit needs to be used and taped to chest (no xmas tree.)

  • Blood pressure goals will be discussed as they evolve during the procedure. This is the primary reason anesthesiologists are requested.

  • Prior to thrombectomy, target BP will be high (permissive hypertension) to promote flow through collateral circulation and perfuse penumbra.

  • Post-thrombectomy, target BP will be lower to minimize reperfusion hemorrhage. Nicardipine is the antihypertensive of choice, but there are other acceptable options (***see dosage guidelines below.) Venodilators may be considered relatively contra-indicated.

  • tPA precautions: Cath lab will let anesthesiologist know upon arrival if tPA was given in ED. tPA can cause angioedema and is a potential cause of airway compromise.



  • When possible, patient should go direct to ICU

  • Anesthesiologist may be needed if patient is going direct to imaging


*** Nicardipine 0.2 mg/mL is available in a 200 mL bag. Initiate at 5 mg/HOUR. If necessary, may increase by 2.5mg/hr, titrated q5min, to a maximum dose of 15mg/hr