Non-intubated general anesthesia with sedation and norepinephrine maintained stable hemodynamics allowing successful middle cerebral artery thrombectomy and discharge without heart failure or hemorrhagic complications in a patient with asynchronous cardio-cerebral infarction.
Case Report (n=1)
No
Non-intubated general anesthesia using sufentanil and remifentanil, guided by echocardiography, provided safe and stable hemodynamic management during mechanical thrombectomy in a high-risk patient with asynchronous cardio-cerebral infarction.
Background Cardio-cerebral infarction (CCI) is a rare syndrome characterized by acute ischemic stroke (AIS) occurring shortly after acute myocardial infarction (AMI). Currently, there are no evidence-based guidelines for perioperative anesthesia management in patients with CCI. Case summary A 58-year-old male underwent coronary stent implantation for acute myocardial infarction (AMI) 4 days prior and was admitted for emergency mechanical thrombectomy due to occlusion of the right middle cerebral artery. Preoperative transthoracic echocardiography revealed left ventricular systolic dysfunction (ejection fraction 40%), segmental wall motion abnormalities, and a left ventricular apical thrombus, this case extends beyond simple post-myocardial infarction thromboembolism because the patient’s AIS occurred in the specific context of acute, severe cardiac dysfunction (EF 40%) with a documented left ventricular thrombus—a direct embolic source stemming from the recent AMI. This fulfills the criteria for “asynchronous cardio-cerebral infarction”, where the brain insult is a direct consequence of the cardiac event within a short temporal window. Anesthesia was managed using a non-intubated general anesthesia approach, involving titration of sedation with sufentanil and remifentanil, combined with norepinephrine to maintain mean arterial pressure (MAP) within ±20% of baseline. The risk of ischemia and hemorrhage was balanced with restrictive fluid management and continuous infusion of tirofiban. Intraprocedural hemodynamics remained stable, and the procedure was successfully completed. The patient was transferred to the general ward on postoperative day three and discharged on day eleven. Troponin I and brain natriuretic peptide (BNP) levels showed a downward trend, with no evidence of heart failure, hemorrhagic transformation, or acute kidney injury. Conclusion In this case of CCI patients, immediate echocardiography was helpful in quickly assessing cardiac function and determining the source of the thrombus. Non-invasive general anesthesia was beneficial in maintaining hemodynamic stability and airway safety. The multidisciplinary individualized anesthesia plan developed in this challenging scenario may provide practical references for perioperative management of similar high-risk CCI patients, but its general applicability still needs to be verified in larger-scale studies.
Zhang et al. (Tue,) conducted a case report in Asynchronous cardio-cerebral infarction with acute ischemic stroke after acute myocardial infarction (n=1). Non-intubated general anesthesia with sedation (sufentanil and remifentanil) and norepinephrine to maintain blood pressure, restrictive fluid management, and continuous infusion of tirofiban was evaluated on Successful reperfusion and stability of hemodynamics during mechanical thrombectomy and postoperative recovery. Non-intubated general anesthesia with sedation and norepinephrine maintained stable hemodynamics allowing successful middle cerebral artery thrombectomy and discharge without heart failure or hemorrhagic complications in a patient with asynchronous cardio-cerebral infarction.