Effect of General Anesthesia and Conscious Sedation During Endovascular Therapy on Infarct Growth and Clinical Outcomes in Acute Ischemic Stroke

Abstract

IMPORTANCE Endovascular therapy (EVT) is the standard of care for select patients who had a stroke caused by a large vessel occlusion in the anterior circulation, but there is uncertainty regarding the optimal anesthetic approach during EVT. Observational studies suggest that general anesthesia (GA) is associated with worse outcomes compared with conscious sedation (CS). OBJECTIVE To examine the effect of type of anesthesia during EVT on infarct growth and clinical outcome. DESIGN, SETTING, AND PARTICIPANTS The General or Local Anesthesia in Intra Arterial Therapy (GOLIATH) trial was a single-center prospective, randomized, open-label, blinded end-point evaluation that enrolled patients from March 12, 2015, to February 2, 2017. Although the trial screened 1501 patients, it included 128 consecutive patients with acute ischemic stroke caused by large vessel occlusions in the anterior circulation within 6 hours of onset; 1372 patients who did not fulfill inclusion criteria and 1 who did not provide consent were excluded. Primary analysis was unadjusted and according to the intention-to-treat principle. INTERVENTIONS Patients were randomized to either the GA group or the CS group (1:1 allocation) before EVT. MAIN OUTCOMES AND MEASURES The primary end point was infarct growth between magnetic resonance imaging scans performed before EVT and 48 to 72 hours after EVT. The hypothesis formulated before data collection was that patients who were under CS would have less infarct growth. RESULTS Of 128 patients included in the trial, 65 were randomized to GA, and 63 were randomized to CS. For the entire cohort, the mean (SD) age was 71.4 (11.4) years, and 62 (48.4%) were women. Baseline demographic and clinical variables were balanced between the GA and CS treatment arms. The median National Institutes of Health Stroke Scale score was 18 (interquartile range [IQR], 14-21). Four patients (6.3%) in the CS group were converted to the GA group. Successful reperfusion was significantly higher in the GA arm than in the CS arm (76.9% vs 60.3%; P = .04). The difference in the volume of infarct growth among patients treated under GA or CS did not reach statistical significance (median [IQR] growth, 8.2 [2.2-38.6] mL vs 19.4 [2.4-79.0] mL; P = .10). There were better clinical outcomes in the GA group, with an odds ratio for a shift to a lower modified Rankin Scale score of 1.91 (95% CI, 1.03-3.56). CONCLUSIONS AND RELEVANCE For patients who underwent thrombectomy for acute ischemic stroke caused by large vessel occlusions in the anterior circulation, GA did not result in worse tissue or clinical outcomes compared with CS. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02317237

Prognostic Significance of Pulse Pressure Variability During Mechanical Thrombectomy in Acute Ischemic Stroke Patients

“…This probably results from the standard of care in our institution, where the anesthesiologists anticipate BP drops in the setting of general anesthesia induction, with the systematical administration of vasopressors. This hypothesis is illustrated in a recent randomized trial in which the volume of infarct growth among patients treated under general anesthesia or conscious sedation was not statistically different and outcomes at 3 months were better in the general anesthesia group 18. In this study, when mean arterial pressure dropped, its duration was not significantly longer for conscious sedation in comparison to general anesthesia patients.…”

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

“…The SIESTA10 and GOLIATH (General or Local Anesthesia in Intra Arterial Therapy, 128 patients)12 trials indeed showed that the proportion of patients having mRs≤2 at 3 months was significantly higher in the GA group. Of note, since the difference in mRs 0–2 was not paralleled by a consistent shift over all mRs categories, these results need to be interpreted with caution.…”

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

“…Currently, three RCTs compared the clinical outcomes of the various anesthesia methods for anterior circulation ischemic stroke, one of which, ANSTROKE (Löwhagen Hendén et al, 2017) showed that the clinical outcomes of the two anesthetic techniques were similar. The other two RCTs, SIESTA (Schönenberger et al, 2016) and GOLIATH (Simonsen et al, 2018), demonstrated that GA did not result in worse clinical outcomes compared with CS. Although a meta-analysis, Ilyas et al, (2018) found that there was no significant difference between the CS group and GA group for acute anterior circulation ischemic stroke using Solitaire stent retriever, there were some limitations such as few studies and the results from a mixture of prospective and retrospective studies.…”

“…shows that our search strategy finally incorporates 13 studies (3 RCTs(Löwhagen Hendén et al, 2017;Schönenberger et al, 2016;Simonsen et al, 2018) and 10 observational studies(Abou- Chebl et al, 2010;Abou-Chebl et al, 2014;Berg et al, 2015;Bracard et al, 2016;John et al, 2014;Jumaa et al, 2010;Shan et al, 2018;Slezak et al, 2017;Whalin et al, 2014)) available for analysis. A total of 2,129 patients underwent endovascular therapy for anterior ischemic stroke by CS, while 1,728 patients by GA.…”