Surgery on Awake Patients May Cut Stroke Risk

Can report problems during a brain angioplasty

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By
HealthDay Reporter

WEDNESDAY, Feb. 19, 2003 (HealthDayNews) -- Opening the clogged brain arteries of stroke-prone patients who are awake during the procedure may reduce the risk of complications, a new study suggests.

The experimental therapy involves inserting a balloon into the blocked artery and inflating it to clear the pathway of obstacles. Later, physicians insert a stent, or a small prop, to hold the artery open.

The operation has traditionally been performed while the patient is under general anesthesia. This can cause serious complications, in part, because physicians can't assess the patient's status in mid-procedure.

In contrast, when the procedure is done under local anesthesia, physicians can communicate with the patient and carefully alter the movement and pressure of the balloon if the patient displays adverse symptoms, says study author Dr. Alex Abou-Chebl, an interventional neurologist at the Cleveland Clinic Foundation.

The Cleveland Clinic team studied the procedure in 11 patients who had a history of stroke or transient ischemic attack (TIA), a less permanently damaging warning stroke.

All were patients who did not respond to the standard preventive treatment for stroke -- aspirin and blood-thinning drugs -- and all elected to undergo the procedure. This subset of patients also had debilitating symptoms: Some had trouble getting out of bed, while others experienced frequent TIAs.

"These are patients at the end of their rope," Abou-Chebl says.

Of the 11 subjects, three experienced serious complications associated with the procedure and one patient died from an adverse reaction to a drug.

At least one of the patients, however, may have been saved by the experimental procedure. The patient reported head pain during angioplasty, prompting the team of physicians to deflate the balloon.

"If we had not known that he had a headache, we would have inflated the balloon further, ruptured the artery, and he would have died on the spot," Abou-Chebl says.

Although patients experience some pain and discomfort under local anesthesia, Abou-Chebl says they tend to prefer the procedure because they are cognizant of what's occurring and they forgo the risks associated with general anesthesia, such as heart attack, brain damage and even death.

Because intracranial angioplasty is an experimental procedure, very few studies have looked at its efficacy.

However, Abou-Chebl suspects the complication rate of 30 percent found with this group of patients is similar to the rate seen in patients who undergo general anesthesia.

"In all three cases [of complications], the neurological assessment heralded the complication and helped guide therapy," Abou-Chebl says. "These results suggest that this procedure is as safe and maybe safer than with general anesthesia."

However, others say the study was too small and the results too mixed to warrant optimism about the technique.

"This doesn't prove that this is such a good idea. This just proves that you can do it," says Dr. Steven Rudolph, a stroke neurologist and director of Lenox Hill Hospital's Stroke Unit in New York City.

"It's much more useful to have people under anesthesia who can't move when you're trying to put something in a blood vessel that measures one millimeter across," he says.

Abou-Chebl agrees that a randomized controlled study in which local and general anesthesia are compared in larger numbers of patients is needed to confirm these findings.

The study was just presented at the International Stroke Conference in Phoenix.

More information

The American Stroke Association has more information on treatment as well as a timeline of advances.

SOURCES: Steven Rudolph, M.D., stroke neurologist and director, stroke unit, Lenox Hill Hospital, New York City; Alex Abou-Chebl, M.D., interventional neurologist, Cleveland Clinic Foundation, Cleveland; Feb. 14, 2003, presentation, International Stroke Conference, Phoenix

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