Emergency intubation during thrombectomy for acute ischemic stroke in patients under primary procedural sedation

Electroacupuncture pretreatment alleviates rats cerebral ischemia-reperfusion injury by inhibiting ferroptosis

Objective

To explore the preventive effect of electroacupuncture pretreatment on stroke in rats by inhibiting ferroptosis and oxidative stress.

Methods

Rats were randomly assigned to the sham, middle cerebral artery occlusion/reperfusion (MCAO/R), MCAO/R + EP, MCAO/R + EP + erastin, and MCAO/R + EP + ferrostatin 1 groups. Daily electroacupuncture was performed 2 weeks before establishing the MCAO/R model utilizing the modified Zea Longa suture method. Rats were sacrificed 1 day after reperfusion, and brain tissues were collected. They were prepared for hematoxylin and eosin staining, prussian blue staining, transmission electron microscope. Measurement of total iron levels using a commercial kit, detection of malondialdehyde (MDA) and superoxide dismutase (SOD) levels by ELISA, and examination of 15-lox2, GPX4, SLC7A11, ACSL4, and TFR1 by western blotting.

Results

Compared with sham rats, cerebral infarction size was dramatically larger in MCAO/R rats. Moreover, the MCAO/R group displayed damaged mitochondria with a disarranged structure of cristae; free iron, total iron levels, and oxidative stress were significantly higher. Cerebral pathological lesions, oxidative stress, total iron levels, and protein levels of ACSL4, TFR1, and 15-lox2 were significantly reduced in the MCAO/R + EP and MCAO/R + EP + ferrostatin 1 groups, while the protective effect of electroacupuncture pretreatment on cerebral ischemia-reperfusion injury was inhibited by treatment with the ferroptosis activator erastin.

Conclusion

Electroacupuncture pretreatment can protect rats from cerebral ischemia-reperfusion injury by reducing the area of cerebral infarction and inhibiting ferroptosis and oxidative stress.

General anesthesia or conscious sedation for thrombectomy in stroke patients: an updated systematic review and meta-analysis

PURPOSE

Endovascular treatment for stroke patients usually requires anesthesia care, with no current consensus on the best anesthetic management strategy. Several randomized controlled trials and meta-analyses have attempted to address this. In 2022, additional evidence from three new trials was published: the GASS trial, the CANVAS II trial, and preliminary results from the AMETIS trial, prompting the execution of this updated systematic review and meta-analysis. The primary objective of this study was to evaluate the effects of general anesthesia and conscious sedation on functional outcomes measured with the modified Rankin scale (mRS) at three months.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials investigating conscious sedation and general anesthesia in endovascular treatment. The following databases were examined: PubMed, Scopus, Embase, and the Cochrane Database of Randomized Controlled Trials and Systematic Reviews. The Risk of Bias 2 tool was used to assess bias. In addition, trial sequence analysis was performed on the primary outcome to estimate if the cumulative effect is significant enough to be unaffected by further studies.

RESULTS

Nine randomized controlled trials were identified, including 1,342 patients undergoing endovascular treatment for stroke. No significant differences were detected between general anesthesia and conscious sedation with regards to mRS, functional independence (mRS, 0-2), procedure duration, onset to reperfusion, mortality, hospital length of stay, and intensive care unit length of stay. Patients treated under general anesthesia may have more frequent successful reperfusion, though the time from groin to reperfusion was slightly longer. Trial sequential analysis showed that additional trials are unlikely to show marked differences in mean mRS at three months.

CONCLUSIONS

In this updated systematic review and meta-analysis, the choice of anesthetic strategy for endovascular treatment of stroke patients did not significantly impact functional outcome as measured with the mRS at three months. Patients managed with general anesthesia may have more frequent successful reperfusion.

TRIAL REGISTRATION

PROSPERO (CRD42022319368); registered 19 April 2022.

General anesthesia but not conscious sedation improves functional outcome in patients receiving endovascular thrombectomy for acute ischemic stroke: A meta-analysis of randomized clinical trials and trial sequence analysis

Background

This study aimed at comparing the difference in prognostic outcomes between patients receiving general anesthesia (GA) and conscious sedation (CS) for endovascular thrombectomy after acute ischemic stroke.

Methods

Databases from Medline, Embase, Google scholar, and Cochrane library were searched for randomized controlled studies (RCTs) comparing patients undergoing GA and CS for endovascular thrombectomy following anterior circulation ischemic stroke. The primary outcome was frequency of 90-day good functional outcome [defined as modified Rankin Scale score of ≤ 2], while secondary outcomes included successful recanalization rate (SRR) [i.e., modified thrombolysis in cerebral infarction = 2b or 3], mortality risk, symptomatic intracranial hemorrhage (ICH), procedure-related complications, hypotension, pneumonia, neurological outcome at post-procedure 24–48 h, and puncture-to-recanalization time.

Results

Six RCTs including 883 patients published between 2016 and 2022 were included. Merged results revealed a higher SRR [risk ratio (RR) = 1.11, 95% CI: 1.03–1.2, p = 0.007; I² = 29%] and favorable neurological outcomes at 3-months (RR = 1.2, 95% CI: 1.01–1.41, p = 0.04; I² = 8%) in the GA group compared to CS group, without difference in the risk of mortality (RR = 0.88), symptomatic ICH (RR = 0.91), procedure-related complications (RR = 1.05), and pneumonia (RR = 1.9) as well as post-procedure neurological outcome (MD = −0.21) and successful recanalization time (MD = 3.33 min). However, GA was associated with a higher risk of hypotension compared with that of CS.

Conclusion

Patients with acute anterior circulation ischemic stroke receiving GA were associated with a higher successful recanalization rate as well as a better 3-month neurological outcome compared to the use of CS. Further investigations are warranted to verify our findings.

Systematic review registration

www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022342483, identifier: CRD42022342483.