1
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Chen H, Xing Y, Lang Z, Zhang L, Liao M, He X. Comparison of anesthesia methods for intra-arterial therapy of patients with acute ischemic stroke: an updated meta-analysis and systematic review. BMC Anesthesiol 2024; 24:243. [PMID: 39026147 DOI: 10.1186/s12871-024-02633-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVES Currently, there remains debate regarding the optimal anesthesia approach for patients undergoing intra-arterial therapy for acute ischemic stroke. Therefore, we conducted a comparative analysis to assess the effects of general anesthesia versus non general anesthesia on patient outcomes. METHODS The research methodology entailed comprehensive searches of prominent databases such as the Cochrane Library, PubMed, Scopus, and Web of Science, covering the period from January 1, 2010, to March 1, 2024. Data synthesis employed techniques like risk ratio or standardized mean difference, along with 95% confidence intervals. The study protocol was prospectively registered with PROSPERO (CRD42024523079). RESULTS A total of 27 trials and 12,875 patients were included in this study. The findings indicated that opting for non-general anesthesia significantly decreased the risk of in-hospital mortality (RR, 1.98; 95% CI: 1.50 to 2.61; p<0.00001; I2 = 20%), as well as mortality within three months post-procedure (RR, 1.24; 95% CI: 1.15 to 1.34; p<0.00001; I2 = 26%), while also leading to a shorter hospitalization duration (SMD, 0.24; 95% CI: 0.15 to 0.33; p<0.00001; I2 = 44%). CONCLUSION Ischemic stroke patients who undergo intra-arterial treatment without general anesthesia have a lower risk of postoperative adverse events and less short-term neurological damage. In routine and non-emergency situations, non-general anesthetic options may be more suitable for intra-arterial treatment, offering greater benefits to patients. In addition to this, the neuroprotective effects of anesthetic drugs should be considered more preoperatively and postoperatively.
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Affiliation(s)
- Huijun Chen
- Dingxi People's Hospital, Dingxi, Gansu, 743000, China
| | - Yang Xing
- The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, 730000, China
- Department of Anesthesia and Surgery, First Hospital of Lanzhou University, Lanzhou, Gansu, 730000, China
| | - Zekun Lang
- The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, 730000, China
| | - Lei Zhang
- The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, 730000, China
| | - Mao Liao
- The Second Clinical Medical College of Lanzhou University, Lanzhou, Gansu, 730000, China
| | - Ximin He
- Dingxi People's Hospital, Dingxi, Gansu, 743000, China.
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2
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Stolp J, Coutinho JM, Immink RV, Preckel B. Anesthetic considerations for endovascular treatment in stroke therapy. Curr Opin Anaesthesiol 2022; 35:472-478. [PMID: 35787587 DOI: 10.1097/aco.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The introduction of clot removement by endovascular treatment (EVT) in 2015 has improved the clinical outcome of patients with acute ischemic stroke (AIS) due to a large vessel occlusion (LVO). Anesthetic strategies during EVT vary widely between hospitals, with some departments employing local anesthesia (LA), others performing conscious sedation (CS) or general anesthesia (GA). The optimal anesthetic strategy remains debated. This review will describe the effects of anesthetic strategy on clinical and radiological outcomes and hemodynamic parameters in patients with AIS undergoing EVT. RECENT FINDINGS Small single-center randomized controlled trails (RCTs) found either no difference or favored GA, while large observational cohort studies favored CS or LA. RCTs using LA as separate comparator arm are still lacking and a meta-analysis of observational studies failed to show differences in functional outcome between LA vs. other anesthetic strategies. Advantages of LA were shorter door-to-groin time in patients and less intraprocedural hypotension, which are both variables that are known to impact functional outcome. SUMMARY The optimal anesthetic approach in patients undergoing EVT for stroke therapy is still unclear, but based on logistics and peri-procedural hemodynamics, LA may be the optimal choice. Multicenter RCTs are warranted comparing LA, CS and GS with strict blood pressure targets and use of the same anesthetic agents to minimize confounding variables.
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Affiliation(s)
| | | | - Rogier V Immink
- Department of Anesthesiology, Amsterdam UMC Location AMC, University of Amsterdam
| | - Benedikt Preckel
- Department of Anesthesiology, Amsterdam UMC Location AMC, University of Amsterdam
- Amsterdam Public Health, Quality of Care
- Amsterdam Cardiovascular Science, Diabetes & Metabolism, Amsterdam, The Netherlands
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3
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Is General Anesthesia for Endovascular Thrombectomy Helpful or Harmful? Can J Neurol Sci 2021; 49:746-760. [PMID: 34511142 DOI: 10.1017/cjn.2021.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endovascular thrombectomy (EVT) has significantly improved outcomes for patients with acute ischemic stroke due to large vessel occlusion. However, despite advances, more than half of patients remain functionally dependent 3 months after their initial stroke. Anesthetic strategy may influence both the technical success of the procedure and overall outcomes. Conventionally, general anesthesia (GA) has been widely used for neuroendovascular procedures, particularly for the distal intracranial circulation, because the complete absence of movement has been considered imperative for procedural success and to minimize complications. In contrast, in patients with acute stroke undergoing EVT, the optimal anesthetic strategy is controversial. Nonrandomized studies suggest GA negatively affects outcomes while the more recent anesthesia-specific RCTs report improved or unchanged outcomes in patients managed with versus without GA, although these findings cannot be generalized to other EVT capable centers due to a number of limitations. Potential explanations for these contrasting results will be addressed in this review including the effect of different anesthetic strategies on cerebral and systemic hemodynamics, revascularization times, and periprocedural complications.
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4
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Wu L, Zhang D, Chen J, Sun C, Ji K, Li W, Zhao W, Li C, Wu C, Li M, Wu D, Ji X. Long-term outcome of endovascular therapy for acute basilar artery occlusion. J Cereb Blood Flow Metab 2021; 41:1210-1218. [PMID: 32955959 PMCID: PMC8142131 DOI: 10.1177/0271678x20958587] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The long-term functional outcome of acute basilar artery occlusion (BAO) patients who received modern endovascular therapy (EVT) is unclear. We sought to assess the long-term functional outcome of BAO patients treated with EVT and determine the prognostic factors associated with favorable outcome. We enrolled consecutive BAO patients who received EVT between December 2012 and December 2018 in this observational study. Baseline characteristics and outcomes were presented. Multivariable logistic regression analysis was performed to identify the prognostic factors associated with long-term outcome. Among the 177 BAO patients included in this study, 80 patients (45.2%) obtained favorable outcome and 97 patients (54.8%) had unfavorable outcome at long-term follow-up with a median observation time of 12 months (interquartile range, 3-19). A total of 67 patients (37.9%) died. National Institutes of Health Stroke Scale (NIHSS), posterior circulation Alberta Stroke Program Early Computed Tomography Score (pc-ASPECTS), time from stroke onset to recanalization, and recanalization condition were identified as independent predictors for long-term outcome. Over 40% of BAO patients who were treated with modern EVT achieved favorable outcome at long-term follow-up. NIHSS, pc-ASPECTS, time from stroke onset to recanalization, and recanalization condition were identified as independent prognostic factors of long-term outcome.
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Affiliation(s)
- Longfei Wu
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Da Zhang
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jian Chen
- Department of Neurosurgery, Capital Medical University, Beijing, China
| | - Chenghe Sun
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Kangxiang Ji
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Weili Li
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Emergency, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Ming Li
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Capital Medical University, Beijing, China
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5
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Butt W, Dhillon PS, Podlasek A, Malik L, Nair S, Hewson D, England TJ, Lenthall R, McConachie N. Local anesthesia as a distinct comparator versus conscious sedation and general anesthesia in endovascular stroke treatment: a systematic review and meta-analysis. J Neurointerv Surg 2021; 14:221-226. [PMID: 33758063 DOI: 10.1136/neurintsurg-2021-017360] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The optimal anesthetic modality for endovascular treatment (EVT) in acute ischemic stroke (AIS) is undetermined. Comparisons of general anesthesia (GA) with composite non-GA cohorts of conscious sedation (CS) and local anesthesia (LA) without sedation have provided conflicting results. There has been emerging interest in assessing whether LA alone may be associated with improved outcomes. We conducted a systematic review and meta-analysis to evaluate clinical and procedural outcomes comparing LA with CS and GA. METHODS We reviewed the literature for studies reporting outcome variables in LA versus CS and LA versus GA comparisons. The primary outcome was 90 day good functional outcome (modified Rankin Scale (mRS) score of ≤2). Secondary outcomes included mortality, symptomatic intracerebral hemorrhage, excellent functional outcome (mRS score ≤1), successful reperfusion (Thrombolysis in Cerebral Infarction (TICI) >2b), procedural time metrics, and procedural complications. Random effects meta-analysis was performed on unadjusted and adjusted data. RESULTS Eight non-randomized studies of 7797 patients (2797 LA, 2218 CS, and 2782 GA) were identified. In the LA versus GA comparison, no statistically significant differences were found in unadjusted analyses for 90 day good functional outcome or mortality (OR=1.22, 95% CI 0.84 to 1.76, p=0.3 and OR=0.83, 95% CI 0.64 to 1.07, p=0.15, respectively) or in the LA versus CS comparison (OR=1.14, 95% CI 0.76 to 1.71, p=0.53 and OR=0.88, 95% CI 0.62 to 1.24, p=0.47, respectively). There was a tendency towards achieving excellent functional outcome (mRS ≤1) in the LA group versus the GA group (OR=1.44, 95% CI 1.00 to 2.08, p=0.05, I2=70%). Analysis of adjusted data demonstrated a tendency towards higher odds of death at 90 days in the GA versus the LA group (OR=1.24, 95% CI 1.00 to 1.54, p=0.05, I2=0%). CONCLUSION LA without sedation was not significantly superior to CS or GA in improving outcomes when performing EVT for AIS. However, the quality of the included studies impaired interpretation, and inclusion of an LA arm in future well designed multicenter, randomized controlled trials is warranted.
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Affiliation(s)
- Waleed Butt
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Permesh Singh Dhillon
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, Nottinghamshire, UK
| | - Anna Podlasek
- NIHR Nottingham Biomedical Research Centre, Nottingham, Nottinghamshire, UK
| | - Luqman Malik
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David Hewson
- Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Vascular Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK.,Vascular Medicine, Division of Medical Sciences and GEM, School of Medicine, University of Nottingham, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Norman McConachie
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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6
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Acute ischemic stroke & emergency mechanical thrombectomy: The effect of type of anesthesia on early outcome. Clin Neurol Neurosurg 2021; 202:106494. [PMID: 33493885 DOI: 10.1016/j.clineuro.2021.106494] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Endovascular mechanical thrombectomy (EMT) is the standard of care for acute ischemic stroke (AIS) caused by proximal large vessel occlusions. There is conflicting evidence on outcome of patients undergoing EMT under procedural sedation (PS) or general anesthesia (GA). In this retrospective study we analyze the effect of GA and PS on the functional outcome of patients undergoing EMT. METHODS Patients who have been admitted at our institute AIS and were treated with EMT under GA or PS between January 2015 and September 2018 were included in the study. Primary end point was the proportion of patients with good functional outcome as defined by a modified Rankin score (mRS) 0-2 at discharge. RESULTS A total of 155 patients were analyzed in this study including 45 (29.03 %) patients who received 97 GA, 110 (70.9 %) PS and 31 of these received Dexmedetomidine/Remifentanil. The median (IQR) 98 mRS at discharge was 4.0 (1.0-4.0) in the GA group Vs 3.00, (1.00-4.00) in the PS group. Among the secondary outcomes the lowest MAP recorded was significantly less in GA group (64.56 100 ± 18.70) compared to PS group (70.86 ± 16.30); p = 0.03. The PS group had a lower odd of mRS 3-5 (after adjustment), however, this finding was statistically not significant (OR 0.52 [0.07-3.5] 102 p = 0.5). CONCLUSIONS Our retrospective analysis did not find any influence of GA compared to PS whenever this was delivered by target controlled infusion (TCI) of propofol or by remifentanil/dexmedetomidine (REX) on early functional outcome.
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7
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Li KHC, Jesuthasan A, Kui C, Davies R, Tse G, Lip GYH. Acute ischemic stroke management: concepts and controversies.A narrative review. Expert Rev Neurother 2020; 21:65-79. [PMID: 33047640 DOI: 10.1080/14737175.2021.1836963] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Amongst the 25.7 million survivors and 6.5 million deaths from stroke between 1990 and 2013, ischemic strokes accounted for approximately 70% and 50% of the cases, respectively. With patients still suffering from complications and stroke recurrence, more questions have been raised as to how we can better improve patient management. AREAS COVERED The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Newcastle-Ottawa Scale (NOS) were adopted to ensure a comprehensive inclusion of quality literature from various sources. PubMed and Embase were searched for evidence on thrombolysis, mechanical thrombectomy, artificial intelligence (AI), antiplatelet therapy, anticoagulation and hypertension management. EXPERT OPINION The directions of future research in these areas are dependent on the current level of validation. Endovascular therapy and applications of AI are relatively new compared to the other areas discussed in this review. As such, future studies need to focus on validating their efficacy. As for thrombolysis, antiplatelet and anticoagulation therapy, their efficacy has been well-established and future research efforts should be directed toward adjusting its use according to patient-specific factors, starting with factors with the most clinical relevance and prevalence.
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Affiliation(s)
- Ka Hou Christien Li
- Medicine, Newcastle University , Newcastle, UK.,Arrowe Park Acute Stroke Unit, Wirral University Teaching Hospital NHS Foundation Trust , Wirral, UK
| | | | | | - Ruth Davies
- Arrowe Park Acute Stroke Unit, Wirral University Teaching Hospital NHS Foundation Trust , Wirral, UK
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University , Tianjin, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool, UK.,Department of Clinical Medicine, Aalborg University , Aalborg, Denmark
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8
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Valent A, Maïer B, Chabanne R, Degos V, Lapergue B, Lukaszewicz AC, Mazighi M, Gayat E. Anaesthesia and haemodynamic management of acute ischaemic stroke patients before, during and after endovascular therapy. Anaesth Crit Care Pain Med 2020; 39:859-870. [PMID: 33039657 DOI: 10.1016/j.accpm.2020.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/16/2020] [Accepted: 05/26/2020] [Indexed: 11/29/2022]
Abstract
Endovascular therapy (EVT) is now standard of care for eligible patients with acute ischaemic stroke caused by large vessel occlusion in the anterior circulation. EVT can be performed with general anaesthesia (GA) or with monitored anaesthesia care, involving local anaesthesia with or without conscious sedation (LA/CS). Controversies remain regarding the optimal choice of anaesthetic strategy and observational studies suggested poorer functional outcome and higher mortality in patients treated under GA, essentially because of its haemodynamic consequences and the delay to put patients under GA. However, these studies are limited by selection bias, the most severe patients being more likely to receive GA and recent randomised trials and meta-analysis showed that protocol-based GA compared with LA/CS is significantly associated with less disability at 3 months. Unlike for intravenous thrombolysis, few data exist to guide management of blood pressure (BP) before and during EVT, but arterial hypotension should be avoided as long as the occlusion persists. BP targets following EVT should probably be adapted to the degree of recanalisation and the extent of ischaemia. Lower BP levels may be warranted to prevent reperfusion injuries even if prospective haemodynamic management evaluations after EVT are lacking.
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Affiliation(s)
- Arnaud Valent
- Department of Anaesthesiology and Critical Care, Lariboisière Hospital, DMU Parabol, AP-HP Nord & University of Paris, Paris, France; UMR-S 942 MASCOT, Inserm, France
| | - Benjamin Maïer
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, 75019 Paris, France
| | - Russell Chabanne
- Department of Perioperative Medicine, University Hospital of Clermont-Ferrand, Clermont-Ferrand Cedex, France
| | - Vincent Degos
- Department of Anaesthesia and Critical Care, Pitié Salpêtrière Hospital, AP-HP-SU, Paris, France, Groupe recherche clinique BIOSFAST, Sorbonne University, Paris, France
| | - Bertrand Lapergue
- Stroke Centre Neurology Division, Hôpital Foch, 92150, Suresnes, France
| | - Anne-Claire Lukaszewicz
- Service d'Anesthésie Réanimation, Hôpital Neurologique, Hospices Civils de Lyon, Bron, France; EA 7426 PI3 (Pathophysiology of Injury-induced Immunosuppression), Hospices Civils de Lyon/Université de Lyon/bioMérieux, Hôpital E. Herriot, Lyon cedex 03, France
| | - Mikael Mazighi
- Department of Neurology and Stroke Centre, Lariboisière Hospital, AP-HP, Paris University, Sorbonne Paris Cité, Paris, France; Département Hospitalo-Universistaire Neurovasc, Paris, France
| | - Etienne Gayat
- Department of Anaesthesiology and Critical Care, Lariboisière Hospital, DMU Parabol, AP-HP Nord & University of Paris, Paris, France; UMR-S 942 MASCOT, Inserm, France.
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9
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Wu L, Jadhav AP, Chen J, Sun C, Ji K, Li W, Zhao W, Li C, Wu C, Wu D, Ji X. Local anesthesia vs general anesthesia during endovascular therapy for acute posterior circulation stroke. J Neurol Sci 2020; 416:117045. [DOI: 10.1016/j.jns.2020.117045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/19/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
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10
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Ganau M, Simonato D, Syrmos N, Tomasi SO, Winkler PA, Prisco L. The continuous quest for a more tailored approach to anesthetic management of patients undergoing endovascular therapy for acute stroke. J Neurointerv Surg 2020; 13:e2. [PMID: 32817135 DOI: 10.1136/neurintsurg-2020-016512] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Mario Ganau
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .,Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Davide Simonato
- Interventional Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nikolaos Syrmos
- School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
| | - Santino O Tomasi
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Peter A Winkler
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Lara Prisco
- Anaesthesia & NeuroIntensive Care, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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11
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Pop R, Severac F, Happi Ngankou E, Harsan O, Martin I, Mihoc D, Manisor M, Simu M, Chibbaro S, Wolff V, Gheoca R, Meyer A, Pottecher J, Audibert G, Derelle AL, Tonnelet R, Liao L, Zhu F, Bracard S, Anxionnat R, Richard S, Beaujeux R, Gory B. Local anesthesia versus general anesthesia during endovascular therapy for acute stroke: a propensity score analysis. J Neurointerv Surg 2020; 13:207-211. [PMID: 32487768 DOI: 10.1136/neurintsurg-2020-015916] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/24/2020] [Accepted: 04/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND To date, the choice of optimal anesthetic management during endovascular therapy (EVT) of acute ischemic stroke patients remains subject to debate. We aimed to compare functional outcomes and complication rates of EVT according to the first-line anesthetic management in two comprehensive stroke centers: local anesthesia (LA) versus general anesthesia (GA). METHODS Retrospective analysis of prospectively collected databases, identifying all consecutive EVT for strokes in the anterior circulation performed between January 1, 2018 and December 31, 2018 in two EVT-capable stroke centers. One center performed EVT under LA in the first intention, while the other center systematically used GA. Using propensity score analysis, the two groups underwent 1:1 matching, then procedural metrics, complications, and clinical outcomes were compared. Good outcome was defined as 90 days modified Rankin Scale (mRS) ≤2, and successful recanalization as modified Thrombolysis In Cerebral Ischemia (mTICI) 2b-3. RESULTS During the study period, 219 patients were treated in the LA center and 142 in the GA center. Using the propensity score, 97 patients from each center were matched 1:1 according to the baseline characteristics. Local anesthesia was associated with a significantly lower proportion of good outcome (36.1% vs 52.0%, OR 0.53, 95% CI 0.33 to 0.87; p=0.039), lower rate of successful recanalization (70.1% vs 95.8%, OR 0.13, 95% CI 0.04 to 0.39; p<0.001), and more procedural complications (14.4% vs 3.0%, OR 3.44, 95% CI 1.09 to 14.28; p=0.018). There were no significant differences in 90-day mortality or symptomatic hemorrhagic transformation rates. CONCLUSIONS In this study, systematic use of GA for stroke EVT was associated with better clinical outcomes, higher recanalization rates, and fewer procedural complications compared with patients treated under LA as the primary anesthetic approach.
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Affiliation(s)
- Raoul Pop
- Interventional Radiology, Institut Hospitalo-Universitaire Strasbourg, Strasbourg, France .,Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - François Severac
- Public Healthcare Department, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Emmanuel Happi Ngankou
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Nancy, Nancy, Lorraine, France
| | - Oana Harsan
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Ioan Martin
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Dan Mihoc
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Monica Manisor
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Mihaela Simu
- Neurology, University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
| | - Salvatore Chibbaro
- Neurosurgery, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Valérie Wolff
- Stroke Unit, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Roxana Gheoca
- Stroke Unit, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Alain Meyer
- Anesthesia, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Julien Pottecher
- Anesthesia, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Gérard Audibert
- Service d'Anesthésie-Réanimation Chirurgicale, Hôpital Central, University Hospital Centre Nancy, Nancy, Lorraine, France.,Faculte de Medecine, Universite de Lorraine, Nancy, Lorraine, France
| | - Anne-Laure Derelle
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Nancy, Nancy, Lorraine, France
| | - Romain Tonnelet
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Nancy, Nancy, Lorraine, France
| | - Liang Liao
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Nancy, Nancy, Lorraine, France
| | - François Zhu
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Nancy, Nancy, Lorraine, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Nancy, Nancy, Lorraine, France
| | - René Anxionnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Nancy, Nancy, Lorraine, France
| | - Sébastien Richard
- Faculte de Medecine, Universite de Lorraine, Nancy, Lorraine, France.,Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, Lorraine, France.,U1116, INSERM, Nancy, France
| | - Rémy Beaujeux
- Interventional Radiology, Institut Hospitalo-Universitaire Strasbourg, Strasbourg, France.,Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Nancy, Nancy, Lorraine, France.,Faculte de Medecine, Universite de Lorraine, Nancy, Lorraine, France.,U1254, INSERM, Nancy, France
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12
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Wu L, Wu D, Yang T, Xu J, Chen J, Wang L, Xu S, Zhao W, Wu C, Ji X. Hypothermic neuroprotection against acute ischemic stroke: The 2019 update. J Cereb Blood Flow Metab 2020; 40:461-481. [PMID: 31856639 PMCID: PMC7026854 DOI: 10.1177/0271678x19894869] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023]
Abstract
Acute ischemic stroke is a leading cause of death and disability worldwide. Therapeutic hypothermia has long been considered as one of the most robust neuroprotective strategies. Although the neuroprotective effects of hypothermia have only been confirmed in patients with global cerebral ischemia after cardiac arrest and in neonatal hypoxic ischemic encephalopathy, establishing standardized protocols and strictly controlling the key parameters may extend its application in other brain injuries, such as acute ischemic stroke. In this review, we discuss the potential neuroprotective effects of hypothermia, its drawbacks evidenced in previous studies, and its potential clinical application for acute ischemic stroke especially in the era of reperfusion. Based on the different conditions between bench and bedside settings, we demonstrate the importance of vascular recanalization for neuroprotection of hypothermia by analyzing numerous literatures regarding hypothermia in focal cerebral ischemia. Then, we make a thorough analysis of key parameters of hypothermia and introduce novel hypothermic therapies. We advocate in favor of the process of clinical translation of intra-arterial selective cooling infusion in the era of reperfusion and provide insights into the prospects of hypothermia in acute ischemic stroke.
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Affiliation(s)
- Longfei Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tuo Yang
- Department of Neurology, Pittsburgh Institute of Brain Disorders and Recovery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jin Xu
- Department of Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Luling Wang
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shuaili Xu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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