Impact of Anesthetic Variation in Endovascular Treatment of Acute Ischemic Stroke

Abstract

Background Given recent technological advancements leading to better outcomes in endovascular therapy for acute ischemic stroke (AIS), updated guidelines recommend thrombectomy as the standard of care in acute large vessel occlusions. However, use of general anesthesia versus conscious sedation continues to be discussed. Two previous randomized trials have shown no significant difference between the use of conscious sedation compared with general anesthesia. Methods The authors performed a retrospective analysis of all consecutive patients with acute ischemia who underwent intra-arterial thrombectomy between September 2014 and May 2020 at a Level 1 stroke center. Patient characteristics along with clinical and operative data were extracted. Frequency distributions of selected characteristics were obtained and statistical significance of any differences according to the mode of anesthesia was assessed. Results A total of 480 patients were included in this study, 257 underwent general anesthesia and 223 underwent conscious sedation. Length of stay (LOS) in the ICU nor length of hospital stay was significantly different between groups. Change in National Institutes of Health Stroke Scale (NIHSS) score from admission to discharge, procedure times, and discharge disposition were not found to be significantly associated with either group although there was a trend towards longer door to puncture time with general anesthesia. Discharge disposition was found to be significantly associated with admission NIHSS (p=0.04). There was a trend towards longer hospital stay in patients with worse admission NIHSS (p=0.09). Success of thrombectomy was not significantly different between both anesthesia groups (p=0.37). Conclusions This large, single-center retrospective cohort study echoes the results of two previous randomized controlled trials in demonstrating non-inferiority of general anesthesia versus conscious sedation in cases of intra-arterial thrombectomy for AIS. These results contrast those of previously published retrospective studies.

Does Tenecteplase Before Mechanical Thrombectomy Result in a Faster Revascularization as Compared to Alteplase? Observations From a Comprehensive Stroke Care Center in Southern India

“…Concerning an association of general anesthesia with time taken for revascularization, several studies have reported conflicting results. Recently, Salehani et al 24 reported a shorted revascularization time in patients who underwent thrombectomy under conscious sedation as opposed to general anesthesia; however, the difference was not statistically significant. 24 A meta-analyses by Campbell et al 25 showed that general anesthesia was associated with significantly prolonged randomization to revascularization time as compared to the conscious sedation group.…”

“…Recently, Salehani et al 24 reported a shorted revascularization time in patients who underwent thrombectomy under conscious sedation as opposed to general anesthesia; however, the difference was not statistically significant. 24 A meta-analyses by Campbell et al 25 showed that general anesthesia was associated with significantly prolonged randomization to revascularization time as compared to the conscious sedation group. Further, the clinical outcomes at 3 months were significantly better in those who underwent endovascular procedure under conscious sedation.…”

Adaptive Approach to Endovascular Management of Large Vessel Occlusion During the COVID-19 Pandemic

“…Historically, approximately half of the thrombectomies performed at our institution are done under conscious sedation rather than general anesthesia, with no apparent implications on discharge disposition or mortality rates. 16 When GA is employed, our pre-pandemic protocol involves intubation in the angiography suite by the anesthesia team, rather than in the emergency department by an emergency medicine physician.…”