Local anesthesia as a distinct comparator versus conscious sedation and general anesthesia in endovascular stroke treatment: a systematic review and meta-analysis

Abstract

BackgroundThe optimal anesthetic modality for endovascular treatment (EVT) in acute ischemic stroke (AIS) is undetermined. Comparisons of general anesthesia (GA) with composite non-GA cohorts of conscious sedation (CS) and local anesthesia (LA) without sedation have provided conflicting results. There has been emerging interest in assessing whether LA alone may be associated with improved outcomes. We conducted a systematic review and meta-analysis to evaluate clinical and procedural outcomes comparing LA with CS and GA.MethodsWe reviewed the literature for studies reporting outcome variables in LA versus CS and LA versus GA comparisons. The primary outcome was 90 day good functional outcome (modified Rankin Scale (mRS) score of ≤2). Secondary outcomes included mortality, symptomatic intracerebral hemorrhage, excellent functional outcome (mRS score ≤1), successful reperfusion (Thrombolysis in Cerebral Infarction (TICI) >2b), procedural time metrics, and procedural complications. Random effects meta-analysis was performed on unadjusted and adjusted data.ResultsEight non-randomized studies of 7797 patients (2797 LA, 2218 CS, and 2782 GA) were identified. In the LA versus GA comparison, no statistically significant differences were found in unadjusted analyses for 90 day good functional outcome or mortality (OR=1.22, 95% CI 0.84 to 1.76, p=0.3 and OR=0.83, 95% CI 0.64 to 1.07, p=0.15, respectively) or in the LA versus CS comparison (OR=1.14, 95% CI 0.76 to 1.71, p=0.53 and OR=0.88, 95% CI 0.62 to 1.24, p=0.47, respectively). There was a tendency towards achieving excellent functional outcome (mRS ≤1) in the LA group versus the GA group (OR=1.44, 95% CI 1.00 to 2.08, p=0.05, I2=70%). Analysis of adjusted data demonstrated a tendency towards higher odds of death at 90 days in the GA versus the LA group (OR=1.24, 95% CI 1.00 to 1.54, p=0.05, I2=0%).ConclusionLA without sedation was not significantly superior to CS or GA in improving outcomes when performing EVT for AIS. However, the quality of the included studies impaired interpretation, and inclusion of an LA arm in future well designed multicenter, randomized controlled trials is warranted.

General anesthesia but not conscious sedation improves functional outcome in patients receiving endovascular thrombectomy for acute ischemic stroke: A meta-analysis of randomized clinical trials and trial sequence analysis

“…Despite a substantially lower anesthetic conversion rate compared with patients receiving local anesthesia without sedation (i.e., 17.5%) ( 34 ), the conversion rate in the current meta-analysis remained high at ~10.3%, which was comparable to that reported in a previous meta-analysis of retrospective studies (i.e., 8.8%) ( 34 ). Conversion from a non-GA approach to GA is known to prolong the procedural time and have a theoretical detrimental effect on neurological outcomes as described in a retrospective clinical report on the effect of conversion from CS to GA ( 9 ).…”

General anesthesia versus conscious sedation during endovascular treatment in posterior circulation large vessel occlusion: A systematic review and meta-analysis

“…Finally, a recent meta-analysis that included 7797 patients from eight non-randomized studies found no differences between GA and CS regarding functional outcomes at 3 months. 10 Information related to the anesthetic approach in patients with PC-LVO is much less well-known. No clinical trials have been conducted so far, although CANVAS-2 is an RCT that is recruiting patients with PC-LVO and results are expected to be completed in December 2023 (ClinicalTrials.…”

Current advances in endovascular treatment

“…In a sub-analysis study from the MR-clean registry, local anaesthesia was associated with better functional outcome compared with general anaesthesia and conscious sedation [25]. In contrary, in a meta-analysis of eight nonrandomized trials, no association was found between anaesthetic type and outcome [26 ▪ ]. Currently, there are eight ongoing RCTs, two of those compare general anaesthesia versus local anaesthesia.…”