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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 PMCID: PMC11256490 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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Batista S, Ferreira MY, Borges J, Oliveira LDB, Slawka E, Bertani R, Besborodco RM, Bocanegra-Becerra JE, Oberman DZ, Almeida Filho JA. Safety of local anesthesia in endovascular treatment of Aneurysms: A systematic review and Meta-Analysis. J Clin Neurosci 2024; 123:47-54. [PMID: 38531194 DOI: 10.1016/j.jocn.2024.03.018] [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: 12/23/2023] [Revised: 02/12/2024] [Accepted: 03/18/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Endovascular treatment of intracranial aneurysms (EVTIAs) is increasingly popular due to its minimally invasive nature and high success rate. While general anesthesia (GA) has been the historical preference for EVTIAs, there's growing interest in local anesthesia (LA). However, concerns persist about LA safety for EVTIAs. Therefore, we conducted a systematic review and meta-analysis to assess LA safety for EVTIAs. METHODS Following PRISMA guidelines, we searched PubMed, Embase, and Web of Science databases. Pooled analysis with 95 % confidence intervals (CI) assessed effects, I2 statistics gauged heterogeneity, and a random-effects model was adopted. Conversion to GA, neurological or procedure-related complications, intraoperative intracranial hemorrhagic complications (IIHC), and mortality were assessed. Subanalyses for ruptured and unruptured cases were performed. RESULTS The analysis included eleven studies, 2,133 patients, and 2,369 EVTIAs under LA. Conversion to GA rate was 1 % (95 %CI: 0 to 2 %). Neurological or procedure-related complications rate was 13 % (95 % CI: 8 % to 17 %). IIHC analysis revealed a rate of 1 % (95 % CI: 1 % to 2 %). The mortality rate was 0 % (95 %CI: 0 % to 0 %). Subanalyses revealed similar rates in ruptured and unruptured subgroups, except for a slightly high rate of complications and IIHC in the ruptured subgroup. CONCLUSION Findings indicate that EVTIA under LA is safe, with low conversion and mortality rates, even for ruptured aneurysms. Complications rates, also in IIHC rates, are comparable to those reported for GA, emphasizing LA's comparable safety profile in EVTIAs. Considering these promising outcomes, the decision to opt for the LA approach emerges as meaningful and well-suited for the endovascular treatment of aneurysms. Beyond its safety, LA introduces inherent supplementary advantages, including shortened hospitalization periods, cost-effectiveness, and an expedited patient recovery process.
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Affiliation(s)
- Sávio Batista
- Federal University of Rio de Janeiro, Faculty of Medicine, Rio de Janeiro, Brazil
| | | | | | | | - Eric Slawka
- Federal University of Rio de Janeiro, Faculty of Medicine, Rio de Janeiro, Brazil
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil
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Zhu X, Zhang Z, Zhong W, He Y, Luo Z, Zhang N, Cheng C, Yang J, Lou M. Effect of anesthesia mode during endovascular treatment on neurological functional outcomes in patients with acute posterior circulation stroke. Zhejiang Da Xue Xue Bao Yi Xue Ban 2024; 53:151-159. [PMID: 38501285 PMCID: PMC11057984 DOI: 10.3724/zdxbyxb-2023-0453] [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: 09/20/2023] [Accepted: 10/23/2023] [Indexed: 03/20/2024]
Abstract
OBJECTIVES To compare the effect of anesthesia mode on the neurological functional outcomes in patients undergoing endovascular treatment for acute posterior circulation ischemic stroke. METHODS Clinical data of 656 patients undergoing intravascular therapy for acute posterior circulation ischemic stroke registered in online Acute Stroke Patients for Stroke Management Quality Evaluation Database from January 2017 to December 2022 were retrospectively analyzed. The data included 163 cases with conscious sedation and 493 cases with general anesthesia during the procedure. After propensity score matching, 428 patients were included in the analysis, including 155 cases in the conscious sedation group and 273 cases in the general anesthesia group. The differences of operation mode, etiology type, vascular recanalization, hemorrhagic transformation at 24 h, modified Rankin Scale (mRS) score at 3 months and mortality within 3 months were compared between the two groups. Binary logistic regression was used to explore the effect of different anesthesia mode on neurological functional outcomes. RESULTS There was a significant difference in operation mode between the two groups (P<0.01), while there were no significant differences in etiology type, vascular recanalization, hemorrhagic transformation at 24 h, mRS score at 3 months or mortality within 3 months (all P>0.05). Binary logistic regression analysis revealed that anesthesia modes were not significantly associated with functional outcomes of patients (OR=1.151, 95%CI: 0.751-1.765, P>0.05). CONCLUSIONS Anesthesia mode (conscious sedation or general anesthesia) will not affect the neurological functional outcomes in patients with acute posterior circulation ischemic stroke undergoing endovascular treatment.
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Affiliation(s)
- Xiaofeng Zhu
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
- Department of Neurology, Tongxiang First People's Hospital, Jiaxing 314500, Zhejiang Province, China.
| | - Zheyu Zhang
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Wansi Zhong
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yaode He
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zhongyu Luo
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Ningyuan Zhang
- Department of Neurology, Tongxiang First People's Hospital, Jiaxing 314500, Zhejiang Province, China
| | - Chaochan Cheng
- Department of Neurology, Yongkang First People's Hospital, Jinhua 321300, Zhejiang Province, China
| | - Jianhong Yang
- Department of Neurology, Ningbo First Hospital, Ningbo 315010, Zhejiang Province, China
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
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Fan B, Qiu LQ, Zhang LC, Li Q, Lu B, Chen GY. General anesthesia vs. conscious sedation and local anesthesia for endovascular treatment in patients with posterior circulation acute ischemic stroke: An updated systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107471. [PMID: 37966095 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107471] [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: 07/14/2023] [Revised: 10/12/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION The best anesthetic choice for patients with acute posterior circulation stroke during endovascular treatment (EVT) remains uncertain. METHOD We searched five databases to identify studies that met the inclusion criteria. Our primary outcome measure was functional independence (FI). Secondary outcomes were 3-month mortality, any intracranial hemorrhage (ICH), symptomatic ICH (sICH), successful reperfusion, and procedure- and ventilator-associated complications. RESULTS A total of 10 studies were included in our meta-analysis. No significant differences were detected between the general anesthesia (GA) and conscious sedation and local anesthesia (CS/LA) groups in 3-month FI (nine studies; OR=0.69; 95% CI 0.45-1.06; P=0.083; I2=66%;), 3-month mortality (nine studies; OR=1.41; 95% CI 0.94-2.11; P=0.096; I2=61.2%;), any ICH (three studies; OR=0.75; 95% CI 0.44-1.25; P=0.269; I2=0%;), or sICH (six studies; OR=0.64; 95% CI 0.40-1.04; P=0.073; I2=0%;). No significant differences were observed for successful reperfusion (10 studies; OR=1.17; 95% CI 0.91-1.49; P=0.219; I2=0%;), procedure-related complications (four studies; OR=1.14; 95% CI 0.70-1.87; P=0.603; I2=7.9%;), or respiratory complications (four studies; OR=1.19; 95% CI 0.61-2.32; P=0.616; I2=64.9%;) between the two groups. CONCLUSIONS Our study showed no differences in 3-month FI, 3-month mortality, and successful reperfusion between patients treated with GA and those treated with CS/LA. Additionally, no increased risk of hemorrhagic transformation or pulmonary infection was observed in the CS/LA group. These results indicate that CS/LA may be an EVT option for acute posterior circulation stroke patients.
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Affiliation(s)
- Bin Fan
- Departments of Anesthesiology, Zigong Fourth People's Hospital, Zigong, Sichuan, China.
| | - Li-Quan Qiu
- Departments of Anesthesiology, Zigong Fourth People's Hospital, Zigong, Sichuan, China.
| | - Li-Cai Zhang
- Departments of Anesthesiology, Zigong Fourth People's Hospital, Zigong, Sichuan, China.
| | - Qiang Li
- Departments of Anesthesiology, Zigong Fourth People's Hospital, Zigong, Sichuan, China.
| | - Bin Lu
- Departments of Anesthesiology, Zigong Fourth People's Hospital, Zigong, Sichuan, China.
| | - Guan-Yu Chen
- Departments of Anesthesiology, Zigong Fourth People's Hospital, Zigong, Sichuan, China.
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Barlinn K, Langezaal LCM, Dippel DWJ, van Zwam WH, Roessler M, Roos YBWEM, Emmer BJ, van Oostenbrugge RJ, Gerber JC, Yoo AJ, Pontes-Neto OM, Mazighi M, Audebert HJ, Michel P, Schonewille WJ, Puetz V. Early Intubation in Endovascular Therapy for Basilar Artery Occlusion: A Post Hoc Analysis of the BASICS Trial. Stroke 2023; 54:2745-2754. [PMID: 37871243 DOI: 10.1161/strokeaha.123.043669] [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: 04/24/2023] [Accepted: 08/30/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND The optimal anesthetic management for endovascular therapy (EVT) in patients with posterior circulation stroke remains unclear. Our objective was to investigate the impact of early intubation in patients enrolled in the BASICS trial (Basilar Artery International Cooperation Study). METHODS BASICS was a multicenter, randomized, controlled trial that compared the efficacy of EVT compared with the best medical care alone in patients with basilar artery occlusion. In this post hoc analysis, early intubation within the first 24 hours of the estimated time of basilar artery occlusion was examined as an additional covariate using regression modeling. We estimated the adjusted relative risks (RRs) for favorable outcomes, defined as modified Rankin Scale scores of 0 to 3 at 90 days. An adjusted common odds ratio was estimated for a shift in the distribution of modified Rankin Scale scores at 90 days. RESULTS Of 300 patients in BASICS, 289 patients were eligible for analysis (151 in the EVT group and 138 in the best medical care group). compared with medical care alone, EVT was related to a higher risk of early intubation (RR, 1.29 [95% CI, 1.09-1.53]; P<0.01), and early intubation was negatively associated with favorable outcome (RR, 0.61 [95% CI, 0.45-0.84]; P=0.002). Whereas there was no overall treatment effect of EVT on favorable outcome (RR, 1.22 [95% CI, 0.95-1.55]; P=0.121), EVT was associated with favorable outcome (RR, 1.34 [95% CI, 1.05-1.71]; P=0.018) and a shift toward lower modified Rankin Scale scores (adjusted common odds ratio, 1.63 [95% CI, 1.04-2.57]; P=0.033) if adjusted for early intubation. CONCLUSIONS In this post hoc analysis of the neutral BASICS trial, early intubation was linked to unfavorable outcomes, which might mitigate a potential benefit from EVT by indirect effects due to an increased risk of early intubation. This relationship may be considered when assessing the efficacy of EVT in patients with basilar artery occlusion in future trials.
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Affiliation(s)
- Kristian Barlinn
- Department of Neurology (K.B., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (K.B., J.C.G., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | | | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands (D.W.J.D.)
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine (W.H.v.Z.), School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
| | - Martin Roessler
- BARMER Institute for Health Care System Research (bifg), Berlin, Germany (M.R.)
| | - Yvo B W E M Roos
- Department of Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, the Netherlands
| | - Bart J Emmer
- Department of Radiology (B.J.E.), Amsterdam University Medical Center, the Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology (R.J.v.O.), School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
| | - Johannes C Gerber
- Dresden Neurovascular Center (K.B., J.C.G., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Institute of Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (J.C.G.)
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth (A.J.Y.)
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Brazil (O.M.P.-N.)
| | - Mikael Mazighi
- Departments of Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Foundation Rothschild Hospital, FHU Neurovasc, INSERM 1144, Paris Cite University, France (M.M.)
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research, Charité Universitätsmedizin Berlin, Germany (H.J.A.)
| | - Patrik Michel
- The Stroke Center, Neurology Service, Lausanne University Hospital, Switzerland (P.M.)
| | - Wouter J Schonewille
- Department of Neurology, St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.)
| | - Volker Puetz
- Department of Neurology (K.B., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (K.B., J.C.G., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
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Tao C, Yuan G, Xu P, Wang H, Zhou P, Yi T, Li K, Cui T, Gao J, Li R, Sun J, Zhang C, Wang L, Liu T, Song J, Yin Y, Nguyen TN, Li Q, Hu W. Anesthetic Management and Outcomes of Endovascular Treatment of Basilar Artery Occlusion: Results From the ATTENTION Registry. J Stroke 2023; 25:399-408. [PMID: 37607695 PMCID: PMC10574300 DOI: 10.5853/jos.2023.00318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/11/2023] [Accepted: 06/07/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND AND PURPOSE To examine the clinical and safety outcomes after endovascular treatment (EVT) for acute basilar artery occlusion (BAO) with different anesthetic modalities. METHODS This was a retrospective analysis using data from the Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION) registry. Patients were divided into two groups defined by anesthetic modality performed during EVT: general anesthesia (GA) or non-general anesthesia (non-GA). The association between anesthetic management and clinical outcomes was evaluated in a propensity score matched (PSM) cohort and an inverse probability of treatment weighting (IPTW) cohort to adjust for imbalances between the two groups. RESULTS Our analytic sample included 1,672 patients from 48 centers. The anesthetic modality was GA in 769 (46.0%) and non-GA in 903 (54.0%) patients. In our primary analysis with the PSM-based cohort, non-GA was comparable to GA concerning the primary outcome (adjusted common odds ratio [acOR], 1.01; 95% confidence interval [CI], 0.82 to 1.25; P=0.91). Mortality at 90 days was 38.4% in the GA group and 35.8% in the non-GA group (adjusted risk ratio, 0.95; 95% CI, 0.83 to 1.08; P=0.44). In our secondary analysis with the IPTW-based cohort, the anesthetic modality was significantly associated with the distribution of modified Rankin Scale at 90 days (acOR: 1.45 [95% CI: 1.20 to 1.75]). CONCLUSION In this nationally-representative observational study, acute ischemic stroke patients due to BAO undergoing EVT without GA had similar clinical and safety outcomes compared with patients treated with GA. These findings provide the basis for large-scale randomized controlled trials to test whether anesthetic management provides meaningful clinical effects for patients undergoing EVT.
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Affiliation(s)
- Chunrong Tao
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Pengfei Xu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Hao Wang
- Department of Neurology, Linyi People’s Hospital, Linyi, China
| | - Peiyang Zhou
- Department of Neurology, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Kai Li
- Department of Neurology, Heze Municipal Hospital, Heze, Shandong, China
| | - Tao Cui
- Department of Neurology, Taihe County People’s Hospital, Fuyang, China
| | - Jun Gao
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Rui Li
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Jun Sun
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Chao Zhang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Li Wang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Tianlong Liu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Jianlong Song
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yamei Yin
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Qing Li
- Department of Laboratory Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Core Facility Center, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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Wang X, Wu Y, Liang F, Jian M, Yu Y, Wang Y, Han R. General Anesthesia Versus Nongeneral Anesthesia for Patients With Acute Posterior Circulation Stroke Undergoing Endovascular Therapy: A Systematic Review and Meta-analysis. J Neurosurg Anesthesiol 2023; 35:274-283. [PMID: 36156053 DOI: 10.1097/ana.0000000000000873] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/30/2022] [Indexed: 11/26/2022]
Abstract
There is continued controversy regarding the optimal anesthetic technique for endovascular therapy in patients with acute posterior circulation ischemic stroke. To compare the clinical outcomes general anesthesia (GA) and non-GA, we performed a systematic review and meta-analysis of randomized controlled trials and observational studies focused on the anesthetic management for endovascular therapy in patients with acute posterior circulation stroke, without language restriction. In addition, we compared clinical outcomes among the studies with different non-GA types (conscious sedation or local anesthesia). Outcome variables were functional independence, excellent outcomes, favorable outcomes, mortality, successful recanalization, hemodynamic instability, intracerebral hemorrhage, and respiratory or vascular complications. Eight studies including 1777 patients were identified. Although GA was associated with a lower odds of functional independence at 90 days (odds ratio [OR]: 0.55; 95% confidence interval [CI] 0.38 to 0.81; P =0.009), substantial heterogeneity was noted ( I2 =65%). Subgroup analysis showed that GA was associated with higher odds of mortality than conscious sedation (OR: 1.83; 95% CI, 1.30 to 2.57; I2 =0%), but there was no difference between GA and local anesthesia ( I2 =0%). Interestingly, subgroup analysis did not identify a relationship between functional independence and GA compared with local anesthesia (OR: 0.90; 95% CI, 0.64 to 1.25; P =0.919; I2 =0%). This meta-analysis demonstrates that GA is associated with worse outcomes in patients with acute posterior circulation stroke undergoing endovascular therapy based on current studies.
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Affiliation(s)
- Xinyan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Anaesthetic and peri-operative management for thrombectomy procedures in stroke patients. Anaesth Crit Care Pain Med 2023; 42:101188. [PMID: 36599377 DOI: 10.1016/j.accpm.2022.101188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE To provide recommendations for the anaesthetic and peri-operative management for thrombectomy procedure in stroke patients DESIGN: A consensus committee of 15 experts issued from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation, SFAR), the Association of French-language Neuro-Anaesthetists (Association des Neuro-Anesthésistes Réanimateurs de Langue Francaise, ANARLF), the French Neuro-Vascular Society (Société Francaise de Neuro-Vasculaire, SFNV), the French Neuro-Radiology Society (Société Francaise de Neuro-Radiologie, SFNR) and the French Study Group on Haemostasis and Thrombosis (Groupe Français d'Études sur l'Hémostase et la Thrombose, GFHT) was convened, under the supervision of two expert coordinators from the SFAR and the ANARLF. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were required to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. METHODS Four fields were defined prior to the literature search: (1) Peri-procedural management, (2) Prevention and management of secondary brain injuries, (3) Management of antiplatelet and anticoagulant treatments, (4) Post-procedural management and orientation of the patient. Questions were formulated using the PICO format (Population, Intervention, Comparison, and Outcomes) and updated as needed. Analysis of the literature was then conducted and the recommendations were formulated according to the GRADE methodology. RESULTS The SFAR/ANARLF/SFNV/SFNR/GFHT guideline panel drew up 18 recommendations regarding anaesthetic management of mechanical thrombectomy procedures. Due to a lack of data in the literature allowing to conclude with high certainty on relevant clinical outcomes, the experts decided to formulate these guidelines as "Professional Practice Recommendations" (PPR) rather than "Formalized Expert Recommendations". After two rounds of rating and several amendments, a strong agreement was reached on 100% of the recommendations. No recommendation could be formulated for two questions. CONCLUSIONS Strong agreement among experts was reached to provide a sizable number of recommendations aimed at optimising anaesthetic management for thrombectomy in patients suffering from stroke.
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Liang F, Wu Y, Wang X, Yan L, Zhang S, Jian M, Liu H, Wang A, Wang F, Han R. General Anesthesia vs Conscious Sedation for Endovascular Treatment in Patients With Posterior Circulation Acute Ischemic Stroke: An Exploratory Randomized Clinical Trial. JAMA Neurol 2023; 80:64-72. [PMID: 36156704 PMCID: PMC9513708 DOI: 10.1001/jamaneurol.2022.3018] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/04/2022] [Indexed: 01/25/2023]
Abstract
Importance No definitive conclusion can be made on the best choice of anesthesia for people with acute posterior circulation stroke during endovascular treatment. Only a few observational studies have focused on this topic in recent years, and they have differing conclusions. Objective To examine whether conscious sedation (CS) is a feasible alternative to general anesthesia (GA) during endovascular treatment in patients with acute posterior circulation stroke. Design, Setting, and Participants A randomized parallel-group exploratory trial with blinded end point evaluation (Choice of Anesthesia for Endovascular Treatment of Acute Ischemic Stroke [CANVAS II]) enrolled adult patients from March 2018 to June 2021 at 2 comprehensive care hospitals in China. Patients with acute posterior circulation stroke were enrolled, randomized, and monitored for 3 months. Of 210 patients admitted with acute ischemic posterior circulation stroke, 93 were recruited and 87 were included in the intention-to-treat (ITT) analysis after exclusions, 43 were assigned to GA and 44 to CS. All analyses were unadjusted or adjusted with the ITT principle. Interventions Participants were randomly assigned to CS or GA in a 1:1 ratio. Main Outcomes and Measures The primary end point was functional independence at 90 days evaluated with the modified Rankin Scale (mRS). Results A total of 87 participants were included in the ITT study (mean [SD] age, 62 [12] years; 16 [18.4%] female and 71 [81.6%] male). Of these, 43 were in the GA group and 44 in the CS group. The overall baseline median (IQR) National Institute of Health Stroke Scale (NIHSS) score was 15 (12-17). In the CS group, 13 people (29.5%) were ultimately transferred to GA. The CS group had a higher incidence of functional independence; however, no significant difference was found between the 2 groups (48.8% vs 54.5%; risk ratio, 0.89; 95% CI, 0.58-1.38; adjusted odds ratio [OR], 0.91; 95% CI, 0.37-2.22). However, GA performed better in successful reperfusion (mTICI 2b-3) under ITT analysis (95.3% vs 77.3%; adjusted OR, 5.86; 95% CI, 1.16-29.53). Conclusion and Relevance The findings in this study suggest that CS was not better than GA for the primary outcome of functional recovery and was perhaps worse for the secondary outcome of successful reperfusion. Trial Registration ClinicalTrials.gov Identifier: NCT03317535.
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Affiliation(s)
- Fa Liang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Youxuan Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Xinyan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Li Yan
- Department of Anesthesiology, Baiyun Hospital, Guizhou Medical University, Guizhou, the People’s Republic of China
| | - Song Zhang
- Department of Anesthesiology, Baiyun Hospital, Guizhou Medical University, Guizhou, the People’s Republic of China
| | - Minyu Jian
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Haiyang Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Anxin Wang
- Department of Statistics, China National Clinical Research Centre for Neurological Diseases, Beijing, the People’s Republic of China
| | - Fan Wang
- Department of Comprehensive Stroke Center, Baiyun Hospital, Guizhou Medical University, Guizhou, the People’s Republic of China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, the People’s Republic of China
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10
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Terceño M, Bashir S, Cienfuegos J, Murillo A, Vera-Monge VA, Pardo L, Reina M, Gubern-Mérida C, Puigoriol-Illamola D, Carballo L, Costa A, Buxó M, Serena J, Silva Y. General anesthesia versus conscious sedation during endovascular treatment in posterior circulation large vessel occlusion: A systematic review and meta-analysis. Eur Stroke J 2022; 8:85-92. [PMID: 37021193 PMCID: PMC10069205 DOI: 10.1177/23969873221127738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/02/2022] [Indexed: 11/15/2022] Open
Abstract
Purpose: The optimal anesthetic approach in the endovascular treatment (EVT) of patients with posterior circulation large vessel occlusion (PC-LVO) strokes is not clear. Little data has been published and no randomized clinical trials have been conducted so far. We aimed to perform an updated meta-analysis to compare clinical and procedural outcomes between conscious sedation (CS) and general anesthesia (GA). Methods: We reviewed the literature of the studies reporting CS and GA in patients with endovascularly-treated PC-LVO. The primary outcome was the functional outcome at 3 months measured using the modified Rankin Scale (mRS). A good functional outcome was defined as having a mRS 0–2. Secondary outcomes were mortality at 3 months, final successful recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) scale from 2b to 3) and complete recanalization (mTICI of 3) and times from stroke onset to EVT completion. Random-effects models were completed to pool the outcomes and the I2 value was calculated to assess heterogeneity. Findings: Eight studies with a total of 1351 patients were included. The pooled results reveal that CS use was associated with higher rates of good outcome (OR 2.41, 95% CI 1.58–3.64, I2 = 49.67%) and with lower mortality at 3 months (OR 0.48, 95% CI 0.28–0.82, I2 =57.11%). No significant differences were observed in the final reperfusion rates, procedural duration, and time from stroke onset to EVT completion. Conclusion: In this meta-analysis, GA was associated with significantly lower rates of functional independence at 3 months in patients with PC-LVO strokes.
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Affiliation(s)
- Mikel Terceño
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
- Mikel Terceño, Unitat d’Ictus, Servei de Neurologia, Hospital Universitari Doctor Josep Trueta de Girona, Av de França s/n, Girona 17007, Spain.
| | - Saima Bashir
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Juan Cienfuegos
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Alan Murillo
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Víctor Augusto Vera-Monge
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Laura Pardo
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Montserrat Reina
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Carme Gubern-Mérida
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Dolors Puigoriol-Illamola
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Laia Carballo
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Anna Costa
- Department of Anesthesiology and Critical Care Medicine, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
| | - Maria Buxó
- Statistical and Methodological Department, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Joaquín Serena
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Yolanda Silva
- Stroke Unit, Department of Neurology, Hospital Universitari Doctor Josep Trueta de Girona, Girona, Spain
- Cerebrovascular Pathology Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
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11
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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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12
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Li F, Wan J, Song J, Yuan J, Kong W, Huang J, Luo W, Wu D, Li L, Chen L, Zhao C, Chen J, Tao H, Sang H, Qiu Z, Zi W, Yang Q, Chen X, Li H, Peng F. Impact of anesthetic strategy on outcomes for patients with acute basilar artery occlusion undergoing mechanical thrombectomy. J Neurointerv Surg 2021; 14:1073-1076. [PMID: 34732534 DOI: 10.1136/neurintsurg-2021-018000] [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: 07/04/2021] [Accepted: 10/20/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND The best anesthetic management strategy for patients with acute large vessel occlusion treated with mechanical thrombectomy (MT) remains uncertain. Most studies have focused on anterior-circulation stroke caused by large artery occlusion. Nevertheless, limited data are available on the appropriate choice of anesthetic for acute basilar artery occlusion (BAO). We aimed to investigate the effect of anesthetic method on clinical outcomes in patients with BAO undergoing MT. METHODS Patients undergoing MT for acute BAO in the BASILAR registry (Acute Basilar Artery Occlusion Study) were included. We divided patients into three groups according to the anesthetic technique used during MT: general anesthesia (GA), local anesthesia (LA), and conscious sedation (CS). Propensity score matching was performed to achieve baseline balance. RESULTS 639 patients were included. GA was used in 257 patients (40.2%), LA was used in 250 patients (39.1%), and CS was used in 132 patients (20.7%). After 1:1 matching, favorable outcome, mortality, and hemorrhagic transformation rates, as well as modified Rankin Scale (mRS) score at 90 days, did not differ between the GA, LA, and CS groups. CONCLUSIONS The choice of anesthetic strategy, GA, LA, or CS, did not affect the clinical outcomes of patients with acute BAO treated with MT in the BASILAR registry.
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Affiliation(s)
- Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Junfang Wan
- Department of Anesthesiology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Junjie Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weilin Kong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Deping Wu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Luming Chen
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chenghao Zhao
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jin Chen
- Department of Quality Control Office, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Hui Tao
- Department of Anesthesiology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Neurology, 903th Hospital of PLA, Hangzhou, Zhejiang, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xingyu Chen
- Department of Neurology, Zhongshan Hospital Xiamen University, Xiamen, Fujian, China
| | - Hong Li
- Department of Anesthesiology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Feng Peng
- Department of Neurology, Zhongshan Hospital Xiamen University, Xiamen, Fujian, China
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13
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Terceño M, Silva Y, Bashir S, Vera-Monge VA, Cardona P, Molina C, Chamorro Á, de la Ossa NP, Hernández-Pérez M, Werner M, Camps-Renom P, Rodríguez-Campello A, Cánovas D, Purroy F, Serena J. Impact of general anesthesia on posterior circulation large vessel occlusions after endovascular thrombectomy. Int J Stroke 2021; 16:792-797. [DOI: 10.1177/1747493020976247] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Background The impact of general anesthesia on functional outcome in patients with large vessel occlusion remains unclear. Most studies have focused on anterior circulation large vessel occlusion; however, little is known about the effect of general anesthesia in patients with posterior circulation—large vessel occlusion. Methods We performed a retrospective analysis from the prospective CICAT registry. All patients with posterior circulation—large vessel occlusion—and undergoing endovascular therapy between January 2016 and January 2020 were included. Demographics, baseline characteristics, procedural data, and anesthesia modality (general anesthesia or conscious sedation) were evaluated. The primary outcome was the proportion of patients with good clinical outcome (modified Rankin Scale score of 0–2) at three months. Results 298 patients underwent endovascular treatment with posterior circulation—large vessel occlusion—were included. Age, diabetes mellitus, renal insufficiency, baseline National Institutes of Health Stroke Scale score, puncture to recanalization length, ≥3 device passes, absent of successful recanalization (defined as treatment in cerebral ischemia of 3), and general anesthesia were statistically associated with poor outcome (mRS: 3-6). In the multivariable regression, general anesthesia and ≥3 device passes were independently associated with poor outcome (aOR: 3.11, (95% CI: 1.34–7.2); P = 0.01 and 3.77, (95% CI: 1.29–11.01); P = 0.02, respectively). Patients treated with general anesthesia were less likely to have a good outcome at three months compared to conscious sedation (19.7% vs. 45.1%, P < 0.001). Conclusions In our study population, general anesthesia use is associated with poor clinical outcome in patients with posterior circulation—large vessel occlusion—treated endovascularly.
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Affiliation(s)
- Mikel Terceño
- Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Doctor Josep Trueta Hospital, Girona, Spain
- Interventional Neuroradiology Unit, Department of Neurosciences, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Yolanda Silva
- Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Doctor Josep Trueta Hospital, Girona, Spain
| | - Saima Bashir
- Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Doctor Josep Trueta Hospital, Girona, Spain
| | - Víctor A Vera-Monge
- Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Doctor Josep Trueta Hospital, Girona, Spain
| | - Pere Cardona
- Stroke Unit, Department of Neurology, Bellvitge Hospital, Barcelona, Spain
| | - Carlos Molina
- Stroke Unit, Department of Neurology, Vall d’Hebron Hospital, Barcelona, Spain
| | - Ángel Chamorro
- Stroke Unit, Department of Neurology, Clinic Hospital, Barcelona, Spain
| | - Natalia P de la Ossa
- Stroke Unit, Department of Neurosciences, Germans Trias i Pujol Hospital, Badalona, Spain
- Stroke Program/Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - María Hernández-Pérez
- Stroke Unit, Department of Neurosciences, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Mariano Werner
- Interventional Neuroradiology Unit, Department of Neurosciences, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Pol Camps-Renom
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - David Cánovas
- Stroke Unit, Department of Neurology, Parc Taulí Hospital, Sabadell, Spain
| | - Francisco Purroy
- Stroke Unit, Department of Neurology, Arnau de Vilanova Hospital, Lleida, Spain
| | - Joaquín Serena
- Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Doctor Josep Trueta Hospital, Girona, Spain
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14
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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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