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Jia Y, Feng Y, Ma Y, Feng G, Xu N, Li M, Liu M, Fan Z, Wang T. Type of anesthesia for endovascular therapy in acute ischemic stroke: A literature review and meta-analysis. Int J Stroke 2024; 19:735-746. [PMID: 38234158 DOI: 10.1177/17474930241228956] [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] [Indexed: 01/19/2024]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) has been proven as the standard treatment for acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). However, the ideal anesthetic strategy during EVT still remains unclear. Therefore, this systematic review and meta-analysis aimed to determine the optimal anesthetic modality for patients with AIS undergoing EVT based on current randomized controlled trials (RCTs). METHODS The databases Medline (via PubMed), EMBASE, Web of Science, and the Cochrane Library were searched for RCTs comparing general anesthesia (GA) and conscious sedation (CS) in AIS patients undergoing EVT. The primary outcome was a favorable functional outcome at 90 days postintervention. Data analysis was conducted using the Review Manager software (RevMan V.5.3). RESULTS Eight RCTs involving 1199 patients were included. There was no significant difference between GA and CS group in the rate of functional independence (risk ratio (RR) = 1.10, 95% confidence interval (CI) = 0.96 to 1.25; p = 0.17; I2 = 30%). Compared with the CS group, the GA group attained a higher successful recanalization rate (RR = 1.14, 95% CI = 1.08 to 1.20; p < 0.00001; I2 = 17%). In addition, patients in the GA were associated with a higher rate of hypotension (RR = 1.87, 95% CI = 1.44 to 2.41; p < 0.00001; I2 = 66%) and a higher incidence of pneumonia (RR = 1.38, 95% CI = 1.05 to 1.8; p = 0.02; I2 = 37%). CONCLUSION For AIS patients receiving EVT, the choice of anesthetic modality did not influence the 3-month neurological outcome while GA is superior to CS in terms of successful reperfusion rate. Moreover, the patients in the GA group were at a higher risk of developing hypotension and pneumonia. Further studies are required to provide more sufficient evidence.
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Affiliation(s)
- Yitong Jia
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yao Feng
- Department of Neurology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yanhui Ma
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guang Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Na Xu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Meng Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Miao Liu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhen Fan
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Ordies S, De Brauwer T, De Beule T, Van Poucke S, Bekelaar K, Van Bylen B, Mesotten D. The effect of anesthesia on hemodynamics and outcome of patients undergoing thrombectomy after acute ischemic stroke: a retrospective analysis. Acta Neurol Belg 2024; 124:523-531. [PMID: 37857938 DOI: 10.1007/s13760-023-02399-4] [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: 05/10/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Anesthesia during thrombectomy remains a matter of debate. We retrospectively investigated the influence of intraprocedural blood pressure and type of anaesthetic agent on 3-month functional outcome and mortality in stroke patients undergoing mechanical thrombectomy under general anesthesia in a single center study. METHODS All patients suffering from stroke who presented between January 2019 and July 2021 at Ziekenhuis Oost-Limburg Genk, Belgium and who received thrombectomy were included. Patient's characteristics and outcome data had been collected for benchmarking. Detailed perioperative data were exported from the electronic anesthesia records and clinically validated. Patients were stratified by peri-operative presence of hypotension (MAP < 65 mmHg at any time point) versus no-hypotension (MAP ≥ 65 mmHg). RESULTS All 98 patients received mechanical thrombectomy under general anesthesia. Thirty-six percent (n = 35) was hypotensive peri-operatively at any time point. Proportion of sevoflurane use was higher in non-hypotensive patients compared to hypotensive patients (73% (n = 45) vs. 51% (n = 18), p = 0.04). Peri-operative use of vasopressors was higher in the hypotensive group compared to non-hypotensive (88% (n = 30) vs. 63% (n = 39), p = 0.008). Proportion of patients with good functional outcome at 3 months (mRS 0-2) was higher in non-hypotensive patients compared to hypotensive patients 44% (n = 27) vs. 24% (n = 8), p < 0.05. 90-day mortality was lower in non-hypotensive patients compared to hypotensive patients 21% (n = 13) vs. 43% (n = 15), (p = 0.02). CONCLUSION Patients who are hypotensive at any given time during thrombectomy under general anesthesia may have worse neurological outcome compared to non-hypotensive patients. The best anaesthetic management for mechanical thrombectomy needs to be clarified prospectively in large multicenter studies.
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Affiliation(s)
- Sofie Ordies
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium.
- University Hospitals Leuven, Leuven, Belgium.
| | - Thomas De Brauwer
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
- University Hospitals Leuven, Leuven, Belgium
| | - Tom De Beule
- Department of Neuroradiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Sven Van Poucke
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Kim Bekelaar
- Department of Neurology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ben Van Bylen
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter Mesotten
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine and Life Sciences, University of Hasselt, Diepenbeek, Belgium
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Chen M, Meis J, Potreck A, Sauer LD, Kieser M, Bendszus M, Wick W, Ringleb PA, Möhlenbruch MA, Schönenberger S. Effect of Individualized Versus Standardized Blood Pressure Management During Endovascular Stroke Treatment on Clinical Outcome: A Randomized Clinical Trial. Stroke 2023; 54:2755-2765. [PMID: 37732489 DOI: 10.1161/strokeaha.123.044062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Optimal blood pressure (BP) management during endovascular stroke treatment is not well established. We studied whether an individualized approach for managing BP during endovascular stroke treatment gives a better clinical outcome than an approach with standardized systolic BP targets. METHODS The INDIVIDUATE study (Individualized Blood Pressure Management During Endovascular Treatment of Acute Ischemic Stroke Under Procedural Sedation) is a randomized clinical trial with a prospective randomized open blinded end point (PROBE) design. Patients were recruited between October 1, 2020 and July 7, 2022 at a single center at a tertiary care university hospital. Patients were eligible, when they were suffering from acute ischemic stroke of the anterior circulation with occlusions of the internal carotid artery and middle cerebral artery and a National Institutes of Health Stroke Scale score of ≥8 receiving endovascular stroke treatment in procedural sedation. The intervention consists of an individualized BP management strategy, where preinterventional baseline systolic BP (SBP) values are used as intraprocedural BP targets. As a control, the standard treatment aims to maintain the intraprocedural SBP between 140 and 180 mm Hg. The main prespecified outcome is the proportion of favorable functional outcomes 90 days after stroke, defined as a modified Rankin Scale score of 0 to 2. RESULTS Two hundred fifty patients were enrolled and included in the analysis, mean (SD) age was 77 (12) years, 142 (57%) patients were women, and mean (SD) National Institutes of Health Stroke Scale score on admission was 17 (5.2). In all, 123 (49%) patients were treated with individualized and 127 (51%) with standard BP management. Mean (SD) intraprocedural SBP was similar in the individualized versus standard BP management group (157 [19] versus 154 [18] mm Hg; P=0.16). The rate of favorable functional outcome after 3 months was not significantly different between the individualized versus the standard BP management group (25% versus 24%; adjusted odds ratio, 0.81 [95% CI, 0.41-1.61]; P=0.56). CONCLUSIONS Among patients treated with endovascular stroke treatment due to an acute ischemic stroke of the anterior circulation, no significant difference was seen between the individualized BP management strategy, where intraprocedural SBP was targeted to baseline values, and the standardized regimen of targeting SBP between 140 and 180 mm Hg. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04578288.
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Affiliation(s)
- Min Chen
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Arne Potreck
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Lukas D Sauer
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Meinhard Kieser
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Martin Bendszus
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Wolfgang Wick
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Peter A Ringleb
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Silvia Schönenberger
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
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Affiliation(s)
- Melinda Davis
- Department of Anesthesiology, Perioperative, and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Campbell D, Butler E, Campbell RB, Ho J, Barber PA. General Anesthesia Compared With Non-GA in Endovascular Thrombectomy for Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Neurology 2023; 100:e1655-e1663. [PMID: 36797071 PMCID: PMC10115505 DOI: 10.1212/wnl.0000000000207066] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 01/03/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular thrombectomy (EVT) for large vessel occlusion ischemic stroke is either performed under general anesthesia (GA) or with non-GA techniques such as conscious sedation or local anesthesia alone. Previous small meta-analyses have demonstrated superior recanalization rates and improved functional recovery with GA when compared with non-GA techniques. The publication of further randomized controlled trials (RCTs) could provide updated guidance when choosing between GA and non-GA techniques. METHODS A systematic search for trials in which stroke EVT patients were randomized to GA or non-GA was performed in Medline, Embase, and the Cochrane Central Register of Controlled Trials. A systematic review and meta-analysis using a random-effects model was performed. RESULTS Seven RCTs were included in the systematic review and meta-analysis. These trials included a total of 980 participants (GA, N = 487; non-GA, N = 493). GA improves recanalization by 9.0% (GA 84.6% vs non-GA 75.6%; odds ratio [OR] 1.75, 95% CI 1.26-2.42, p = 0.0009), and the proportion of patients with functional recovery improves by 8.4% (GA 44.6% vs non-GA 36.2%; OR 1.43, 95% CI 1.04-1.98, p = 0.03). There was no difference in hemorrhagic complications or 3-month mortality. DISCUSSION In patients with ischemic stroke treated with EVT, GA is associated with higher recanalization rates and improved functional recovery at 3 months compared with non-GA techniques. Conversion to GA and subsequent intention-to-treat analysis will underestimate the true therapeutic benefit. GA is established as effective in improving recanalization rates in EVT (7 Class 1 studies) with a high Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) certainty rating. GA is established as effective in improving functional recovery at 3 months in EVT (5 Class 1 studies) with a moderate GRADE certainty rating. Stroke services need to develop pathways to incorporate GA as the first choice for most EVT procedures in acute ischemic stroke with a level A recommendation for recanalization and level B recommendation for functional recovery.
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Affiliation(s)
- Douglas Campbell
- From the Auckland City Hospital (D.C., E.B.); University of Otago (R.B.C.), Dunedin; and University of Auckland (J.H., P.A.B.), New Zealand.
| | - Elise Butler
- From the Auckland City Hospital (D.C., E.B.); University of Otago (R.B.C.), Dunedin; and University of Auckland (J.H., P.A.B.), New Zealand
| | - Ruby Blythe Campbell
- From the Auckland City Hospital (D.C., E.B.); University of Otago (R.B.C.), Dunedin; and University of Auckland (J.H., P.A.B.), New Zealand.
| | - Jess Ho
- From the Auckland City Hospital (D.C., E.B.); University of Otago (R.B.C.), Dunedin; and University of Auckland (J.H., P.A.B.), New Zealand
| | - P Alan Barber
- From the Auckland City Hospital (D.C., E.B.); University of Otago (R.B.C.), Dunedin; and University of Auckland (J.H., P.A.B.), New Zealand
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Campbell D, Butler E, Barber PA. End the confusion: general anaesthesia improves patient outcomes in endovascular thrombectomy. Br J Anaesth 2022; 129:461-464. [PMID: 35868883 DOI: 10.1016/j.bja.2022.06.018] [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: 03/22/2022] [Revised: 05/23/2022] [Accepted: 06/17/2022] [Indexed: 11/22/2022] Open
Abstract
Expert physiological and pharmacological care by anaesthetists is required in all stroke endovascular thrombectomy cases. RCTs show clinical benefits in recanalisation rates and functional recovery after endovascular thrombectomy with general anaesthesia compared with sedation. Many stroke centres will require wholesale reorganisation of stroke pathways to ensure anaesthesia services are available for all cases. Anaesthetists have an integral role in improving clinical outcomes in large vessel occlusion stroke.
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Affiliation(s)
| | | | - P Alan Barber
- Auckland City Hospital, Auckland, New Zealand; University of Auckland, Auckland, New Zealand
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Maïer B, Gory B, Chabanne R, Tavernier B, Balanca B, Audibert G, Thion LA, Le Guen M, Geeraerts T, Calviere L, Degos V, Lapergue B, Richard S, Djarallah A, Mophawe O, Boursin P, Le Cossec C, Blanc R, Piotin M, Mazighi M, Gayat E. Effect of an individualized versus standard blood pressure management during mechanical thrombectomy for anterior ischemic stroke: the DETERMINE randomized controlled trial. Trials 2022; 23:598. [PMID: 35883180 PMCID: PMC9317065 DOI: 10.1186/s13063-022-06538-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hypotension and blood pressure (BP) variability during endovascular therapy (EVT) for acute ischemic stroke (AIS) due to an anterior large vessel occlusion (LVO) is associated with worse outcomes. However, the optimal BP threshold during EVT is still unknown given the lack of randomized controlled evidence. We designed the DETERMINE trial to assess whether an individualized BP management during EVT could achieve better functional outcomes compared to a standard BP management. Methods The DETERMINE trial is a multicenter, prospective, randomized, controlled, open-label, blinded endpoint clinical trial (PROBE design). AIS patients with a proximal anterior LVO are randomly assigned, in a 1:1 ratio, to an experimental arm in which mean arterial pressure (MAP) is maintained within 10% of the first MAP measured before EVT, or a control arm in which systolic BP (SBP) is maintained within 140–180 mm Hg until reperfusion is achieved or artery closure in case of EVT failure. The primary outcome is the rate of favorable functional outcomes, defined by a modified Rankin Scale (mRS) between 0 and 2 at 90 days. Secondary outcomes include excellent outcome and ordinal analysis of the mRS at 90 days, early neurological improvement at 24 h (National Institutes of Health Stroke Scale), final infarct volume, symptomatic intracranial hemorrhage rates, and all-cause mortality at 90 days. Overall, 432 patients will be included. Discussion DETERMINE will assess the clinical relevance of an individualized BP management before reperfusion compared to the one size fits all approach currently recommended by international guidelines. Trial registration ClinicalTrials.gov, NCT04352296. Registered on 20th April 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06538-9.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France. .,Université Paris-Cité, Paris, France.
| | - Benjamin Gory
- Diagnostic and Therapeutic Neuroradiology Department, CHRU-Nancy, Université de Lorraine, INSERM U124, Nancy, France
| | - Russell Chabanne
- Department of Anesthesia, Critical Care and Peri-Operative Medicine, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Benoît Tavernier
- Department of Anesthesia and Critical Care, University Hospital, Lille, F-59000, Lille, France.,Université Lille, ULR 2694 - METRICS, F-59000, Lille, France
| | - Baptiste Balanca
- Department of Neurological Anesthesiology and Intensive Care, Hospices Civils de Lyon, Hôpital Pierre Wertheimer, Groupement Hospitalier Est, 59 Boulevard Pinel, 69500, Bron, Lyon, France.,Lyon's Neuroscience Research Center, INSERM U1028/CNRS UMR 5292, Lyon 1 University, Lyon, France
| | | | - Laurie-Anne Thion
- Anesthesiology Department, Hôpital fondation A. de Rothschild, Paris, France
| | - Morgan Le Guen
- Anesthesiology Department, Foch Hospital, Suresnes, France
| | - Thomas Geeraerts
- Anesthesiology and Critical Care department, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Lionel Calviere
- Neurology Department, University Hospital of Toulouse, Toulouse, France
| | - Vincent Degos
- Department of Anesthesia, Critical Care and Peri-Operative Medicine, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France.,INSERM UMR 1141, Paris, France
| | | | - Sebastien Richard
- Neurology Department, CHRU-Nancy, Université de Lorraine, Nancy, France
| | - Azeddine Djarallah
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Ornellia Mophawe
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Perrine Boursin
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Chloé Le Cossec
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Raphael Blanc
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France.,Université Paris-Cité, Paris, France
| | - Etienne Gayat
- Université Paris-Cité, Paris, France.,Anesthesiology Department, Hôpital Lariboisière, Paris, France
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