General Anesthesia Versus Conscious Sedation in Endovascular Thrombectomy for Stroke: A Meta-analysis of 4 Randomized Controlled Trials

Abstract

Background: In ischemic stroke patients, studies have suggested that clinical outcomes following endovascular thrombectomy are worse after general anesthesia (GA) compared with conscious sedation (CS). Most data are from observational trials, which are prone to measure and unmeasure confounding. We performed a systematic review and meta-analysis of thrombectomy trials where patients were randomized to GA or CS, and compared efficacy and safety outcomes. Methods: The Medline, Embase, and Cochrane databases were searched for randomized controlled trials comparing GA to CS in endovascular thrombectomy. Efficacy outcomes included successful recanalization (Thrombolysis in Cerebral Infarction score of 2b to 3), and good functional outcome, defined as a modified Rankin Scale score of 0 to 2 at 3 months. Safety outcomes included intracerebral hemorrhage and 3-month mortality. Results: Four studies were identified and included in the random effects meta-analysis. Patients treated with GA achieved a higher proportion of successful recanalization (odds ratio [OR]: 2.14, 95% confidence interval [CI]: 1.26-3.62; P=0.005) and good functional outcome (OR: 1.71, 95% CI: 1.13-2.59; P=0.01). For every 7.9 patients receiving GA, one more achieved good functional outcome compared with those receiving CS. There were no significant differences in intracerebral hemorrhage (OR: 0.61, 95% CI: 0.20-1.85; P=0.38) or 3-month mortality (OR: 0.62, 95% CI: 0.33-1.17; P=0.14) between GA and CS patients. Conclusions: In centers with high quality, specialized neuroanesthesia care, GA treated thrombectomy patients had superior recanalization rates and better functional outcome at 3 months than patients receiving CS.

A pilot randomised controlled trial of the management of systolic blood pressure during endovascular thrombectomy for acute ischaemic stroke

“…Secondly, the larger trial will be limited to endovascular thrombectomy with general anaesthesia. There is evidence that: outcomes after general anaesthesia may be superior to conscious sedation [30];…”

“…Secondly, the larger trial will be limited to endovascular thrombectomy with general anaesthesia. There is evidence that: outcomes after general anaesthesia may be superior to conscious sedation ; haemodynamic targeting is challenging during conscious sedation; and the effects of systolic blood pressure augmentation may be enhanced due to additional impairment of cerebral autoregulation.…”

International experience of mechanical thrombectomy during the COVID-19 pandemic: insights from STAR and ENRG

“…Somewhat paradoxically, significantly higher number of patients were intubated in LCC prior to MT, which was associated with longer door to reperfusion times. Evidence from clinical trials indicates that GA is non-inferior to MAC in patients undergoing MT [24][25][26] and in clinical practice there is considerable variability. In this study, 241/458 (52.6%) of the patients underwent planned pre-procedure GA, and only 2/194 (1%) required emergent, unplanned intra-procedural intubation.…”

The year in review - neuroanaesthesia and neurointensive care

“…Pacienti s celkovou anestezií měli větší procento úspěšných rekanalizací a dobrý funkční výsledek. Nebyl zjištěn rozdíl mezi intracerebrálním krvácením a 3 měsíční smrtností [12].…”