Is mechanical embolectomy performed in nonanesthetized patients effective?

Is General Anesthesia for Endovascular Thrombectomy Helpful or Harmful?

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.

Anaesthesia and haemodynamic management of acute ischaemic stroke patients before, during and after endovascular therapy

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.

Choice of ANaesthesia for EndoVAScular treatment of acute ischaemic stroke at posterior circulation (CANVAS II): protocol for an exploratory randomised controlled study

INTRODUCTION

Observational and interventional studies indicate that the type of anaesthesia may be associated with the postprocedural neurological function in patients with anterior circulation acute ischaemic stroke undergoing endovascular treatment. Patients with acute posterior circulation ischaemic stroke may experience different physiological changes and result in severe neurological outcome. However, the effect of the type of anaesthesia on postprocedure neurological function remained unclear in this population.

METHODS AND ANALYSIS

This is an exploratory randomised controlled trial that will be carried out at Beijing Tiantan Hospital, Capital Medical University. Patients with acute posterior circulation ischaemic stroke and deemed suitable for emergency endovascular recanalisation will be recruited in this trial. Eighty-four patients will be randomised to receive either general anaesthesia or conscious sedation with 1:1 allocation ratio. The primary endpoint is the 90-day modified Rankin Scale.

ETHICS AND DISSEMINATION

The study has been reviewed by and approved by Ethics Committee of Beijing Tiantan Hospital of Capital Medical University (KY2017-074-02). If the results are positive, the study will indicate whether the type of anaesthesia affects neurological outcome after endovascular treatment of posterior stroke. The findings of the study will be published in peer-reviewed journals and presented at national or international conferences.

TRIAL REGISTRATION NUMBER

NCT03317535.

Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 1: Patient Characteristics, Determinants of Effectiveness, and Effect of Blood Pressure on Outcome

In the United States, stroke ranks fifth among all causes of death and is the leading cause of serious long-term disability. The 2018 American Heart Association stroke care guidelines consider endovascular thrombectomy to be the standard of care for patients who have acute ischemic stroke in the anterior circulation when arterial puncture can be made within 6 hours of symptom onset or within 6-24 hours of symptom onset when specific eligibility criteria are satisfied. The aim of this 2-part review is to provide practical perspective on the clinical literature regarding anesthesia care of patients treated with endovascular thrombectomy. Part 1 (this article) reviews the development of endovascular thrombectomy and the determinants of endovascular thrombectomy effectiveness irrespective of method of anesthesia. The first aim of part 1 is to explain why rapid workflow and maintenance of blood pressure are necessary to help support the ischemic brain until, as a result of endovascular thrombectomy, reperfusion is accomplished. The second aim of part 1, understanding the nonanesthesia factors determining endovascular thrombectomy effectiveness, is necessary to identify numerous biases present in observational reports regarding anesthesia for endovascular thrombectomy. With this background, in part 2 (the companion to this article), the observational literature is briefly summarized, largely to identify its weaknesses, but also to develop hypotheses derived from it that have been recently tested in 3 randomized clinical trials of sedation versus general anesthesia for endovascular thrombectomy. In part 2, these 3 trials are reviewed both from a functional outcomes perspective (meta-analysis) and a methodological perspective, providing specifics regarding anesthesia and hemodynamic management. Part 2 concludes with a pragmatic approach to anesthesia decision making (sedation versus general anesthesia) and acute phase anesthesia management of patients treated with endovascular thrombectomy.

Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 2: Integrating and Applying Observational Reports and Randomized Clinical Trials

The 2018 American Heart Association stroke care guidelines consider endovascular thrombectomy to be the standard of care for patients who have acute ischemic stroke in the anterior circulation when arterial puncture can be made: (1) within 6 h of symptom onset; or (2) within 6-24 h of symptom onset when specific eligibility criteria are satisfied. The aim of this 2-part review is to provide practical perspective on the clinical literature regarding anesthesia care of endovascular thrombectomy patients. In the preceding companion article (part 1), the rationale for rapid workflow and maintenance of blood pressure before reperfusion were reviewed. Also in part 1, the key patient and procedural factors determining endovascular thrombectomy effectiveness were identified. In this article (part 2), the observational literature regarding anesthesia for endovascular thrombectomy is summarized briefly, largely to identify its numerous biases, but also to develop hypotheses regarding sedation versus general anesthesia pertaining to workflow, hemodynamic management, and intra- and post-endovascular thrombectomy adverse events. These hypotheses underlie the conduct and outcome measures of 3 recent randomized clinical trials of sedation versus general anesthesia for endovascular thrombectomy. A meta-analysis of functional outcomes from these 3 trials show, when managed according to trial protocols, sedation and general anesthesia result in outcomes that are not significantly different. Details regarding anesthesia and hemodynamic management from these 3 trials are provided. This article concludes with a pragmatic approach to real-time anesthesia decision-making (sedation versus general anesthesia) and the goals and methods of acute phase anesthesia management of endovascular thrombectomy patients.

Outcomes of general anesthesia versus conscious sedation for Stroke undergoing endovascular treatment: a meta-analysis

Background

The impact of anesthesia strategy on the outcomes of acute ischemic stroke (AIS) patients undergoing endovascular treatment is currently controversy. Thus, we performed this meta-analysis to compare the differences of clinical and angiographic outcomes between general anesthesia (GA) and conscious sedation (CS).

Methods

A literature search in PubMed, Embase, and Web of Knowledge databases through February 2019 was conducted for related records on GA and CS of AIS undergoing endovascular treatment. The results of the studies were pooled and meta-analyzed with fixed- or random-effect model based on heterogeneity test in total and subgroup analyses.

Results

Twenty-three studies including 6703 patients were analyzed in this meta-analysis. We found that patients in the GA group have lower odds of favorable functional outcome (mRS scores ≤2) compared with the CS group (odds ratio [OR] = 0.62, 95% confidence interval [CI]: 0.49–0.77), and higher risk of mortality (OR = 1.68, 95% CI: 1.49–1.90), pneumonia (OR = 1.78, 95% CI: 1.40–2.26), symptomatic intracranial hemorrhage (OR = 1.64, 95% CI: 1.13–2.37). However, no significant differences were seen between the groups in the rate of recanalization (OR = 1.07, 95% CI: 0.89–1.28), vessel dissection or perforation (OR = 1.00, 95% CI: 0.98–1.03) and asymptomatic intracranial hemorrhage (OR = 1.19, 95% CI: 0.96–1.47). While in the RCT subgroup analysis, we found patients in the GA group does not show lower rate of favorable functional outcome compared with the CS group (OR = 1.84, 95% CI: 1.17–2.89). And there was no significant difference in the rate of mortality between GA and CS groups during RCT subgroup analysis (OR = 0.74, 95% CI: 0.43–1.27).

Conclusions

AIS patients performed endovascular treatment under GA compared with CS was associated with worse functional outcome and increased rate of mortality, but differences in worsened outcomes do not exist when one looks into the GA vs. CS RCTs. Moreover, these findings are mainly based on the retrospective studies and additional multi-center randomized controlled trials to definitively address these issues is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0741-7) contains supplementary material, which is available to authorized users.

Influence of Anesthesia Type on Outcomes after Endovascular Treatment in Acute Ischemic Stroke: Meta-Analysis

PURPOSE

To assess clinical and angiographic outcomes after endovascular treatment (EVT) in ischemic stroke patients according to anesthesia types (general anesthesia vs. conscious sedation).

MATERIALS AND METHODS

A systematic literature review through an online data base between January 1990 and September 2017 was performed. A fixed effect model was used in cases of <50% heterogeneity. The primary outcomes were good clinical outcome at the 3-month follow-up and successful recanalization. A meta-regression analysis was done to estimate primary outcomes of log odds ratio (OR) on onset-to-puncture time (OTP) differences. Publication bias was determined using Begg's funnel plot and additional the Trim and Fill method.

RESULTS

Sixteen articles including 2,662 patients (general anesthesia, n=1,275; conscious sedation, n=1,387) were included. General anesthesia significantly decreased good outcomes than conscious sedation (OR, 0.564; 95% confidence interval [CI], 0.354-0.899). However, outcomes did not differ significantly in randomized controlled trials (RCTs; OR, 1.101; 95% CI, 0.395-3.071). Anesthesia type was not associated with successful recanalization (OR, 0.985; 95% CI, 0.787-1.233). General anesthesia increased the risk of mortality (OR, 1.532; 95% CI, 1.187-1.976) and pneumonia (OR, 1.613; 95% CI, 1.172-2.221), but not symptomatic intracranial hemorrhage (OR, 1.125; 95% CI, 0.767-1.652). The meta-regression analysis showed no linear relationship between OTP differences and log OR of good outcome (coefficient, 0.0004; P=0.95) or successful recanalization (coefficient, 0.0005; P=0.94), respectively.

CONCLUSION

General anesthesia seemed to be associated with adverse clinical outcome after EVT. However, its efficacy was not demonstrated in RCTs. Successful recanalization did not differ according to anesthesia type. Studies using individual patient data based on further RCTs are necessary to elucidate anesthesia effect on procedural and clinical outcomes.

Anesthetic management of endovascular treatment for acute ischemic stroke: Influences on outcome and complications

Background and objectives

The emerging use of endovascular therapies for acute ischemic stroke, like intra-arterial thrombectomy, compels a better understanding of the anesthetic management required and its impact in global outcomes. This article reviews the available data on the anesthetic management of endovascular treatment, comparing general anesthesia with conscious sedation, the most used modalities, in terms of anesthetic induction and procedure duration, patient mobility, occlusion location, hemodynamic parameters, outcome and safety; it also focuses on the state-of-the-art on physiologic and pharmacologic neuroprotection.

Contents

Most of the evidence on this topic is retrospective and contradictory, with only three small randomized studies to date. Conscious sedation was frequently associated with better outcomes, but the prospective evidence declared that it has no advantage over general anesthesia concerning that issue. Conscious sedation is at least as safe as general anesthesia for the endovascular treatment of acute ischemic stroke, with equivalent mortality and fewer complications like pneumonia, hypotension or extubation difficulties. It has, however, a higher frequency of patient agitation and movement, which is the main cause for conversion to general anesthesia.

Conclusions

General anesthesia and conscious sedation are both safe alternatives for anesthetic management of patients submitted to endovascular thrombectomy. No anesthetic management is universally recommended and hopefully the ongoing randomized clinical trials will shed some light on the best approach; meanwhile, the choice of anesthesia should be based on the patient's individual characteristics. Regarding neuroprotection, hemodynamic stability is currently the most important strategy, as no pharmacological method has been proven effective in humans.

"Real life" impact of anesthesia strategy for mechanical thrombectomy on the delay, recanalization and outcome in acute ischemic stroke patients

BACKGROUND AND PURPOSE

Choice of anesthesia type on outcome for mechanical thrombectomy (MT) in acute ischemic stroke remains controversial. The goal of our research was to study the impact of anesthesia strategy on the delay, angiographic and neurological outcome of MT performed under general anesthesia (GA) vs. conscious sedation (CS).

METHODS

This prospective, single-center observational study included patients with anterior circulation large vessel occlusion (ACLVO) strokes treated with MT within 6 hours of symptom onset. All time metrics were evaluated. Angiographic and clinical outcomes were assessed by recanalization rate (mTICI) and 3-month functional independence (mRs). Complications and mortality rate were recorded as safety outcomes.

RESULTS

In total, 303 consecutive thrombectomies were performed, 86.8% under GA. NIHSS was higher in GA, with median of 19.0 for GA and 16.5 for CS (P = 0.049). Median time from arrival in hospital (door) to groin puncture was 83 min (IQR = 45.0-109.5) for GA compared to 72 min (IQR = 35.0-85.3) for CS, P = 0.170). Median time from arrival in the angiosuite to groin puncture was 20 min (IQR = 15.0-29.0) for GA compared to 15 min (IQR = 10.0-20.0) for CS, P = 0.017). There were no significant differences in recanalization time metrics, successful revascularization rate, functional independence and mortality rate at three months.

CONCLUSIONS

GA induced a 5 to 10 minutes delay for groin puncture, without impact on recanalization time metrics, or neurological outcome at 3 months. Our results demonstrate that a well-organized workflow is associated with reasonable delay in performing GA for MT, without effect on outcome compared to sedation.

[Anesthetic management of endovascular treatment for acute ischemic stroke: Influences on outcome and complications]

BACKGROUND AND OBJECTIVES

The emerging use of endovascular therapies for acute ischemic stroke, like intra-arterial thrombectomy, compels a better understanding of the anesthetic management required and its impact in global outcomes. This article reviews the available data on the anesthetic management of endovascular treatment, comparing general anesthesia with conscious sedation, the most used modalities, in terms of anesthetic induction and procedure duration, patient mobility, occlusion location, hemodynamic parameters, outcome and safety; it also focuses on the state-of-the-art on physiologic and pharmacologic neuroprotection.

CONTENTS

Most of the evidence on this topic is retrospective and contradictory, with only three small randomized studies to date. Conscious sedation was frequently associated with better outcomes, but the prospective evidence declared that it has no advantage over general anesthesia concerning that issue. Conscious sedation is at least as safe as general anesthesia for the endovascular treatment of acute ischemic stroke, with equivalent mortality and fewer complications like pneumonia, hypotension or extubation difficulties. It has, however, a higher frequency of patient agitation and movement, which is the main cause for conversion to general anesthesia.

CONCLUSIONS

General anesthesia and conscious sedation are both safe alternatives for anesthetic management of patients submitted to endovascular thrombectomy. No anesthetic management is universally recommended and hopefully the ongoing randomized clinical trials will shed some light on the best approach; meanwhile, the choice of anesthesia should be based on the patient's individual characteristics. Regarding neuroprotection, hemodynamic stability is currently the most important strategy, as no pharmacological method has been proven effective in humans.

Current evidence for anesthesia management during endovascular stroke therapy: updated systematic review and meta-analysis

Introduction

Debate continues about the optimal anesthetic management for patients undergoing endovascular treatment (ET) of acute ischemic stroke due to emergent large vessel occlusion.

Objective

To compare, using current evidence, the clinical outcomes and procedural characteristics among patients undergoing general anesthesia (GA) and local or monitored anesthesia (non-GA).

Methods

We performed a systematic review and meta-analysis of all available studies that involved the use of stent retrievers for ET (stentriever group). Additionally, we included studies that were published in 2015 and later, and compared the clinical outcomes among the studies using stentrievers or no stentrievers (pre-stentriever group). Outcome variables included functional independence (FI; modified Rankin Scale scores of 0–2), symptomatic hemorrhage, mortality, procedure duration, and vascular and respiratory complications. We calculated pooled odds ratios and 95% CIs using random-effects models.

Results

Sixteen studies (three randomized controlled clinical trials (RCTs) and 13 non-randomized studies) were identified comprising 5836 patients. Although non-GA was associated with higher odds of 3-month FI (OR=1.57; 95% CI 1.17 to 2.10; P=0.003) and lower odds of 3-month mortality (OR=0.62; 95% CI 0.47 to 0.82; P=0.0006, substantial heterogeneity was noted across included trials. Sensitivity analyses of RCTs showed that non-GA was inversely associated with FI (OR=0.55; 95% CI 0.34 to 0.89; P=0.01; I2=15%), while no association was noted with mortality (OR=1.36; 95% CI 0.79 to 2.34; P=0.27; I2=0%).

Conclusion

Our updated meta-analysis demonstrates favorable results with non-GA, probably owing to inclusion of non-randomized studies. Recent single-center RCTs indicate that GA is associated with higher odds of FI at 3 months, while other outcomes are similar between the two groups.

Conscious Sedation versus General Anesthesia for Patients with Acute Ischemic Stroke Undergoing Endovascular Therapy: A Systematic Review and Meta-Analysis

The aim of this study is to compare the effect of conscious sedation (CS) with general anesthesia (GA) on clinical outcomes in patients with acute ischemic stroke (AIS) undergoing endovascular therapy (EVT). MEDLINE, EMBASE, and Cochrane Central Registers of Controlled Trials (from inception to July 2017) were searched for reports on CS and GA of AIS undergoing EVT. Two reviewers assessed the eligibility of the identified studies and extracted data. Data were analyzed using the fixed-effects model, and the sources of heterogeneity were explored by sensitive analysis. Trial sequential analysis was conducted to monitor boundaries for the limitation of global type I error, and GRADE system was demonstrated to evaluate the quality of evidence. A total of thirteen studies were finally identified. Pooled analysis of the incidence of mRS score ≦ 2 after hospital discharge and one or three months in the CS group was higher than that in the GA group. The all-causing mortality of AIS patients in the CS group was lower than that in the GA group. There were no differences in the proportion of IA rtPA and thrombolysis between the two groups. Compared with AIS patients receiving GA, the all-causing mortality in the AIS patients receiving CS was decreased, while incidence of mRS score ≦ 2 at hospital discharge and one or three months was increased.

General Anesthesia Versus Conscious Sedation for Endovascular Treatment of Acute Ischemic Stroke

Background and Purpose—

Retrospective studies have found that patients receiving general anesthesia for endovascular treatment in acute ischemic stroke have worse neurological outcome compared with patients receiving conscious sedation. In this prospective randomized single-center study, we investigated the impact of anesthesia technique on neurological outcome in acute ischemic stroke patients.

Methods—

Ninety patients receiving endovascular treatment for acute ischemic stroke in 2013 to 2016 were included and randomized to general anesthesia or conscious sedation. Difference in neurological outcome at 3 months, measured as modified Rankin Scale score, was analyzed (primary outcome) and early neurological improvement of National Institutes of Health Stroke Scale and cerebral infarction volume. Age, sex, comorbidities, admission National Institutes of Health Stroke Scale score, intraprocedural blood pressure, blood glucose, Paco 2 and Pco 2 modified Thrombolysis in Cerebral Ischemia score, and relevant time intervals were recorded.

Results—

In the general anesthesia group 19 of 45 patients (42.2%) and in the conscious sedation group 18 of 45 patients (40.0%) achieved a modified Rankin Scale score ≤2 ( P =1.00) at 3 months, with no differences in intraoperative blood pressure decline from baseline ( P =0.57); blood glucose ( P =0.94); PaCO2 ( P =0.68); time intervals ( P =0.78); degree of successful recanalization, 91.1% versus 88.9% ( P =1.00); National Institutes of Health Stroke Scale score at 24 hours 8 (3–5) versus 9 (2–15; P =0.60); infarction volume, 20 (10–100) versus 20(10–54) mL ( P =0.53); and hospital mortality (13.3% in both groups; P =1.00).

Conclusions—

In endovascular treatment for acute ischemic stroke, no difference was found between general anesthesia and conscious sedation in neurological outcome 3 months after stroke.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01872884.

Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic Stroke: Protocol for a randomized controlled (CANVAS) trial

Background

Observational studies indicate that the type of anesthesia, local or general, may be associated with the post-procedural neurological function in patients with acute ischemic stroke undergoing endovascular treatment. However, these results need further confirmation, and the causal relationship has not yet been established.

Methods

This is a randomized controlled equivalence trial. Permuted block randomization stratified by culprit vessels will be used. Six hundred and forty patients with acute ischemic stroke undergoing endovascular recanalization will be randomized one to one to receive either general anesthesia or local anesthesia. The primary endpoint is the modified Rankin scale at 90 days after endovascular treatment. The secondary endpoints are the peri-procedural mortality and morbidity.

Discussion

The study aims to determine the effects of anesthetic choice on neurological outcomes in patients with acute ischemic stroke undergoing intra-arterial recanalization. If the results are positive, the study will indicate that the type of anesthesia does not affect neurological outcome after endovascular treatment. Trial registration: ClinicalTrial.gov identifier: NCT02677415

Anesthesia Technique and Outcomes of Mechanical Thrombectomy in Patients With Acute Ischemic Stroke

BACKGROUND AND PURPOSE

The impact of anesthesia technique on the outcomes of mechanical thrombectomy for acute ischemic stroke remains an issue of debate. We investigated the association of general anesthesia with outcomes in patients undergoing mechanical thrombectomy for ischemic stroke.

METHODS

We performed a cohort study involving patients undergoing mechanical thrombectomy for ischemic stroke from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. An instrumental variable (hospital rate of general anesthesia) analysis was used to simulate the effects of randomization and investigate the association of anesthesia technique with case-fatality and length of stay.

RESULTS

Among 1174 patients, 441 (37.6%) underwent general anesthesia and 733 (62.4%) underwent conscious sedation. Using an instrumental variable analysis, we identified that general anesthesia was associated with a 6.4% increased case-fatality (95% confidence interval, 1.9%-11.0%) and 8.4 days longer length of stay (95% confidence interval, 2.9-14.0) in comparison to conscious sedation. This corresponded to 15 patients needing to be treated with conscious sedation to prevent 1 death. Our results were robust in sensitivity analysis with mixed effects regression and propensity score-adjusted regression models.

CONCLUSIONS

Using a comprehensive all-payer cohort of acute ischemic stroke patients undergoing mechanical thrombectomy in New York State, we identified an association of general anesthesia with increased case-fatality and length of stay. These considerations should be taken into account when standardizing acute stroke care.

[Intubation and sedation in the endovascular treatment of acute cerebral infarction]

In the past complex intracranial treatments demanded intubation and general anesthesia of the patient. With increasing rate of endovascular local treatment of acute stroke more and more neurointerventionalists report that recanalisation techniques can be performed in sedation of the patient without the need of additional intubation. Although prospective studies are lacking retrospective studies have shown that the risk of iatrogeneous vessel injuries without global anesthesia is not increased but outcomes in case of conscious sedations are better compared with intubation and general anesthesia.

Hypotension During Endovascular Treatment of Ischemic Stroke Is a Risk Factor for Poor Neurological Outcome

Background and Purpose—

In retrospective studies, patients receiving general anesthesia for endovascular treatment for acute ischemic stroke have worse neurological outcome compared with patients receiving conscious sedation. It has been suggested that this is caused by general anesthesia–associated hypotension. We investigated the effect of intraprocedural hypotension on neurological outcome.

Methods—

One hundred eight patients with acute ischemic stroke, who underwent endovascular treatment in general anesthesia between 2007 and 2012, were included. Analyzed predictors of neurological outcome were age, sex, comorbidities, baseline National Institutes of Health Stroke Scale, intraprocedural relative changes in mean arterial blood pressure from baseline, blood glucose, modified Thrombolysis in Cerebral Infarction score, and elapsed time from stroke to computed tomography, groin puncture, and recanalization/end of procedure.

Results—

A fall in mean arterial blood pressure of >40% was an independent predictor for poor neurological outcome ( P =0.032), as were higher admission National Institutes of Health Stroke Scale score ( P =0.008) and lack of recanalization ( P =0.003).

Conclusions—

Profound intraprocedural hypotension is an independent predictor for poor neurological outcome in patients with acute ischemic stroke undergoing endovascular therapy in general anesthesia.

Sedation vs. Intubation for Endovascular Stroke TreAtment (SIESTA) – A Randomized Monocentric Trial

Background

The optimal peri-interventional management of sedation and airway for endovascular stroke treatment (EST) appears to be a crucial factor for treatment success. According to retrospective studies, the widely favored general anesthesia with intubation seems to be associated with poor functional outcome compared to a slightly sedated non-intubated condition (conscious sedation).

Method

SIESTA is a monocentric, prospective, randomized parallel-group, open-label treatment trial with blinded endpoint evaluation (PROBE design). The study compares the non-intubated with the intubated state in patients receiving endovascular treatment of acute ischemic anterior circulation stroke. The primary endpoint is early neurological improvement as by National Institutes of Health Stroke Scale (NIHSS) after 24 h (difference between NIHSS on admission and NIHSS after 24 h). Secondary endpoints include: functional outcome after three-months as by modified Rankin Scale (mRS), mortality, parameters of ventilation and critical care, feasibility, and safety, i.e. complications related to endovascular stroke treatment.

Conclusion

The aims of this study are to prospectively clarify whether the non-intubated state of conscious sedation is feasible, safe, and superior with regard to early neurological improvement compared to the intubated state of general anesthesia in patients receiving acute endovascular stroke treatment.

Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types.

MATERIALS AND METHODS

In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization.

RESULTS

Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87-3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36-3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35-0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37-0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score.

CONCLUSIONS

Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association.