Conscious Sedation Versus General Anesthesia During Endovascular Therapy for Acute Anterior Circulation Stroke

Abstract

Background and Purpose-Patients undergoing intra-arterial therapy (IAT) for acute ischemic stroke receive either general anesthesia (GA) or conscious sedation. GA may delay time to treatment, whereas conscious sedation may result in patient movement and compromise the safety of the procedure. We sought to determine whether there were differences in safety and outcomes in GA patients before initiation of IAT. Methods-A cohort of 980 patients at 12 stroke centers underwent IAT for acute stroke between 2005 and 2009. Only patients with anterior circulation strokes due to large-vessel occlusion were included in the study. A binary logistic-regression model was used to determine independent predictors of good outcome and death. Results-The mean age was 66Ϯ15 years and median National Institutes of Health Stroke Scale score was 17 (interquartile range, 13-20). The overall recanalization rate was 68% and the symptomatic hemorrhage rate was 9.2%. GA was used in 44% of patients with no differences in intracranial hemorrhage rates when compared with the conscious sedation group. The use of GA was associated with poorer neurologic outcome at 90 days (odds ratioϭ2.33; 95% CI, 1.63-3.44; PϽ0.0001) and higher mortality (odds ratioϭ1.68; 95% CI, 1.23-2.30; PϽ0.0001) compared with conscious sedation. Conclusions-Patients placed under GA during IAT for anterior circulation stroke appear to have a higher chance of poor neurologic outcome and mortality. There do not appear to be differences in hemorrhagic complications between the 2 groups. Future clinical trials with IAT can help elucidate the etiology of the differences in outcomes. (Stroke. 2010; 41:1175-1179.)

Intra-arterial Therapy for Acute Ischemic Stroke

“…Others have argued that IAT should be performed under GA to make the procedure safer by avoiding inadvertent wire perforation due to patient motion. A recent study by the author (Abou-Chebl [33]) and his colleagues casts doubt into the validity of these concerns. In a pooled analysis of 980 consecutive patients from 12 medical centers receiving IAT, those treated under GA had a greater than 2-fold risk of poor outcomes and a nearly 2-fold risk of death [33].…”

“…A recent study by the author (Abou-Chebl [33]) and his colleagues casts doubt into the validity of these concerns. In a pooled analysis of 980 consecutive patients from 12 medical centers receiving IAT, those treated under GA had a greater than 2-fold risk of poor outcomes and a nearly 2-fold risk of death [33]. Importantly, those treated while awake did not have any increase in the risk of ICH or wire perforation.…”

Anesthetic Care for Acute Ischemic Stroke: Facts and Aspirations

“…However, data from multiple retrospective studies show a correlation between the use of general anesthesia (GA) and worse outcome. For example, one multicenter study showed that GA was associated with worse functional outcomes as assessed by the mRS than monitored anesthesia care (MAC), based on data from 980 patients who underwent mechanical recanalization (13). Other retrospective studies have come to similar conclusions, with GA associated with worse functional outcomes (i.e., a mRS score >2) (14,15), parenchymal hemorrhage (16), and higher in-hospital mortality (16).…”

“…Patients receiving GA may harbor a cerebral infarct that is more extensive and advanced, are unable to cooperate or protect their airways, or have other major comorbidities. Indeed, in many of these retrospective studies, patients receiving GA had higher pre-procedural National Institutes of Health Stroke Scale (NI-HSS) scores, indicating that they had more symptomatic strokes prior to endovascular intervention (13)(14)(15). The difference in baseline neurological status is an independent predictor of worse outcomes, including death (14,16).…”

Endovaskuläre Therapie des akut ischämischen Schlaganfalls unter Analgosedierung im Vergleich zur Intubationsnarkose - Durchführbarkeit, periprozedurale Sicherheit, klinisches und radiologisches Outcome

“…In Analogie zu Jumaa et al [10] fand sich in der vorliegenden Studie sowohl bei Verschlüssen im vorderen (6,5 ± 3,7 Tage vs. 9,6 ± 4,1 Tage) als auch im hinteren (6,3 ± 2,9 Tage vs. 7,9 ± 3,7 [24]. In 2 weiteren aktuellen Studien konnte die Korrelation zwischen Intubationsnarkose und schlechterem klinischem Outcome bestätigt werden [25,26]. Eine mögliche weitere Erklärung hierfür ist, dass sich die Penumbra in Abhängigkeit von der Dauer fehlender Reperfusion zugunsten des Infarktkerns zurückbildet und hieraus ein schlechteres Outcome resultiert [10].…”