Tolga D Dittrich, MD
@to_dittrich

Wagner B, Lorscheider J, Wiencierz A, Blackham K, Psychogios M, Bolliger D, De Marchis GM, Engelter ST, Lyrer P, Wright PR, et al. Endovascular Treatment for Acute Ischemic Stroke With or Without General Anesthesia: A Matched Comparison. Stroke. 2022.

Endovascular treatment (EVT) effectively treats acute ischemic stroke and has gained increasing importance over the last few years. An important peri-procedural question is the choice of anesthesia type, especially whether conscious sedation (CS) is preferable to general anesthesia (GA). The current recommendation is that this decision should be made individually based on patient characteristics (e.g., aspiration risk) and technical feasibility.1 Based on data from the Swiss Stroke Registry, Wagner and colleagues investigated the influence of anesthesia type on functional outcome at three months in patients receiving EVT for anterior circulation stroke.

Anesthesia types were defined as GA (i.e., endotracheal intubation) and non-GA (i.e., CS or no sedation). Of the total 1,284 patients, two-thirds received GA and one-third non-GA. In propensity score-matched analysis, GA patients had higher modified Rankin Scale scores (N=568; OR 1.61 [1.20-2.15]) and higher odds for dependency or death (OR 1.49 [1.07-2.07]) at three months compared with non-GA patients. In general, a potential delay of treatment initiation and arterial blood pressure fluctuations during EVT with GA were mentioned as explanatory factors for better functional outcomes in the non-GA group. However, door-to-groin puncture times did not substantially differ, and information on arterial blood pressure during the procedure was not available.

In the largest randomized controlled trials (RCTs) on EVT, CS was chosen in most cases.2-5 In terms of functional outcome, there was no strong signal of superiority of one anesthetic method over the other. So far, observational studies and monocentric RCTs on this topic with limited sample sizes have yielded partly contradictory results. Potential explanations for these differences could be: (i) Heterogeneity in the group compositions. While GA usually refers to endotracheal intubation with deep sedation, in “non-GA” groups the spectrum ranges from moderate sedation to no sedation; (ii) Different in- and exclusion criteria of RCTs, e.g., regarding the inclusion of severely agitated patients; (iii) Selection bias in the observational studies, e.g., due to the selection of GA in more severely affected individuals.

The present study derived from real-life clinical data points toward a worse functional outcome after EVT under GA compared to CS or no sedation in experienced Swiss stroke centers. Major strengths are the large sample size, especially in the often-underrepresented group of patients receiving GA, and the performance of matched analyses to account for observed confounders. Limitations are the lack of randomization (with potential residual confounding) and missing information on the type of anesthetic and blood pressure trajectories during EVT. More extensive, multicenter RCTs are needed to clarify this issue. Until then, it seems reasonable to make an individualized choice of anesthetic technique in experienced stroke centers.

References:

1.           Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the american heart association/american stroke association. Stroke. 2019;50:e344-e418

2.           Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019-1030

3.           Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-pa vs. T-pa alone in stroke. N Engl J Med. 2015;372:2285-2295

4.           Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378:708-718

5.           Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378:11-21