title: Rigorous anaesthesia management protocol for patients with intracranial arterial stenosis: a prospective controlled-cohort study.
abstract: OBJECTIVE
  Reducing variability is integral in quality management. As part of the ongoing Encephaloduroarteriosynangiosis Revascularisation for Symptomatic Intracranial Arterial Stenosis (ERSIAS) trial, we developed a strict anaesthesia protocol to minimise fluctuations in patient parameters affecting cerebral perfusion. We hypothesise that this protocol reduces the intraoperative variability of targeted monitored parameters compared to standard management.
  
  
  METHODS
  Prospective cohort study of patients undergoing encephaloduroarteriosynangiosis surgery versus standard neurovascular interventions. Patients with ERSIAS had strict perioperative management that included normocapnia and intentional hypertension. Control patients received regular anaesthetic standard of care. Minute-by-minute intraoperative vitals were electronically collected. Heterogeneity of variance tests were used to compare variance across groups. Mixed-model regression analysis was performed to establish the effects of treatment group on the monitored parameters.
  
  
  METHODS
  Tertiary care centre.
  
  
  METHODS
  24 participants: 12 cases (53.8 years ± 16.7 years; 10 females) and 12 controls (51.3 years ± 15.2 years; 10 females). Adults aged 30-80 years, with transient ischaemic attack or non-disabling stroke (modified Rankin Scale <3) attributed to 70-99% intracranial stenosis of the carotid or middle cerebral artery, were considered for enrolment. Controls were matched according to age, gender and history of neurovascular intervention.
  
  
  METHODS
  Variability of heart rate, mean arterial blood pressure (MAP), systolic blood pressure and end tidal CO2 (ETCO2) throughout surgical duration.
  
  
  RESULTS
  There were significant reductions in the intraoperative MAP SD (4.26 vs 10.23 mm Hg; p=0.007) and ETCO2 SD (0.94 vs 1.26 mm Hg; p=0.05) between the ERSIAS and control groups. Median MAP and ETCO2 in the ERSIAS group were higher (98 mm Hg, IQR 23 vs 75 mm Hg, IQR 15; p<0.001, and 38 mm Hg, IQR 4 vs 32 mm Hg, IQR 3; p<0.001, respectively).
  
  
  CONCLUSIONS
  The ERSIAS anaesthesia protocol successfully reduced intraoperative fluctuations of MAP and ETCO2. The protocol also achieved normocarbia and the intended hypertension.
  
  
  BACKGROUND
  NCT01819597; Pre-results.
authors.affiliation: Department of Neurosurgery, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA.
authors.forename: Azim N
authors.initials: AN
authors.lastname: Laiwalla
authors.affiliation: Department of Neurosurgery, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA.
authors.forename: Yinn Cher
authors.initials: YC
authors.lastname: Ooi
authors.affiliation: Department of Anesthesiology, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA.
authors.forename: Barbara
authors.initials: B
authors.lastname: Van De Wiele
authors.affiliation: Department of Anesthesiology, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA.
authors.forename: Keren
authors.initials: K
authors.lastname: Ziv
authors.affiliation: Department of Anesthesiology, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA.
authors.forename: Adam
authors.initials: A
authors.lastname: Brown
authors.affiliation: Department of Neurosurgery, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA.
authors.forename: Raymond
authors.initials: R
authors.lastname: Liou
authors.affiliation: Department of Neurology, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA.
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Saver
authors.affiliation: Department of Neurosurgery and Radiology, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA.
authors.forename: Nestor R
authors.initials: NR
authors.lastname: Gonzalez
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000758:Anesthesia / Q000379:methods* / Q000592:standards; D016893:Carotid Stenosis / Q000601:surgery*; D016022:Case-Control Studies; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D016343:Monitoring, Intraoperative; D010043:Outcome and Process Assessment, Health Care; D011446:Prospective Studies; D012044:Regression Analysis; D055986:Vital Signs
keywords: NEUROSURGERY; STROKE MEDICINE