Anaesthetic management during intracranial mechanical thrombectomy: systematic review and meta-analysis of current data

Abstract

ObjectiveOur aim was to compare the clinical outcome of patients with ischaemic stroke with anterior large vessel occlusion treated with stent retrievers and/or contact aspiration mechanical thrombectomy (MT) under general anaesthesia (GA) or conscious sedation non-GA through a systematic review and meta-analysis.MethodsThe literature was searched using PubMed, Embase and Cochrane databases to identify studies reporting on anaesthesia and MT. Using fixed or random weighted effect, we evaluated the following outcomes: 3-month mortality, modified Rankin Score (mRs) 0–2, recanalisation success (thrombolysis in cerebral infarction (TICI) ≥2b) and symptomatic intracerebral haemorrhagic (sICH) transformation.ResultsWe identified seven cohorts (including three dedicated randomised controlled trials), totalling 1929 patients (932 with GA). Over the entire sample, mortality, mRs 0–2, TICI≥2b and sICH rates were, respectively 17.5% (99% CI 9.7% to 29.6%; Q-value: 60.1; I2: 93%, 1717 patients), 42.1% (99% CI 33.3% to 51.7%; Q-value: 41.3; I2: 87.9%), 82.9% (99% CI 74.0% to 89.1%; Q-value: 20.7; I2: 80.6%, 1006 patients) and 5.5% (99% CI 2.8% to 10.8%; Q-value: 18.6; I2: 78.5%). MT performed in non-GA patients was associated with better 3-month functional outcome (pooled OR, 1.35; 99% CI 1.04 to 1.76; Q-value: 24.0; I2: 9.2%, 1845 patients) and lower 3-month mortality rate (pooled OR, 0.70; 99% CI 0.49 to 0.98; Q-value: 1.4; I2: 0%, 1717 patients; fixed weighted effect model) compared with GA. MT performed under conscious sedation non-GA had significantly shorter onset-to-recanalisation and onset-to-groin delay compared with GA, and recanalisation success and sICH were similar.ConclusionNon-GA during MT for anterior acute ischaemic stroke with current-generation stent retriever/aspiration devices is associated with better 3-month functional outcome and lower mortality rates. These unadjusted estimates are subject to biases and should be interpreted with caution.

Anesthesia for endovascular treatment in anterior circulation stroke: A systematic review and meta‐analysis

“…Contrary to the four previous meta-analysis (Brinjikji et al, 2017;Campbell et al, 2018;Gravel et al, 2018;Ilyas et al, 2018) that only have a single aspect of results from both RCTs and observational studies or RCTs, our meta-analysis separately analyzed them and found that the inconsistencies were remarkable between the RCTs and the observational studies, further advancing the understanding of controversy in the choice of anesthesia methods during endovascular therapy for anterior circulation ischemic stroke. Both RCTs and observational studies have strengths and limitations that finally affect their results.…”

“…Contrary to the four previous meta-analysis (Brinjikji et al, 2017;Campbell et al, 2018;Gravel et al, 2018;Ilyas et al, 2018) that onset to EVT and no limit to the NIHSS scores (Slezak et al, 2017)), thus, they are more powered to estimate the safety endpoints. (Campbell et al, 2016;Saber, Rajah, Kherallah, Jadhav, & Narayanan, 2018).…”

“…However, except for the EKOS devices used in IMS II (Nichols et al, 2010), the other first thrombectomy devices were still used in many studies (Kim, Son, Kang, Hwang, & Kim, 2017;Lapergue et al, 2016). Thus, unlike the previous meta-analysis, Ilyas et al (2018); Gravel et al (2018), only including the modern devices, some observational studies (Abou Chebl et al, 2015;Jumaa et al, 2010) in our study utilized the first devices. Although we performed subanalysis to adjust for the thrombectomy devices, the heterogeneity was difficult to be eliminated.…”

Scoping review of mode of anaesthesia in emergency surgery

“…Non‐randomized studies which concluded that non‐general is superior to general anaesthesia often had no clear description of the anaesthesia delivered. By contrast, in meta‐analyses , of RCTs where extensive descriptions of the type of anaesthesia delivered were reported, including agents and doses, along with ventilation and physiological parameters, general anaesthesia was reported to be superior. Unless all constituent components are reported and accounted for, the discrepancy of reporting of anaesthesia risks conclusions being made with serious confounding.…”

In‐hospital acute stroke workflow in acute stroke – Systems‐based approaches

“…The optimal type of anaesthesia for improving patient outcomes and in‐hospital workflows is widely discussed in scientific literature, with meta‐analyses and observational studies reporting worse workflow and clinical implications with GA. Two meta‐analyses by Janssen et al 63 and Brinjikji et al 69 report a door‐to‐treatment time reduction of 12 and 14 minutes, respectively, in favour of local anaesthesia/conscious sedation; however, the inclusion of observational studies introduces potential selection bias. The results of numerous RCT’s, retrospective studies and meta‐analyses affirm workflow delays with GA and associated poorer clinical outcomes and mortality 70‐72 . This contrasts with results from numerous observational studies including Peng et al, 73 Simonsen et al, 74 and Henden et al 75 , which conclude a statistically insignificant effect of conscious sedation on clinical outcomes in comparison to GA.…”