Anesthesia-related outcomes for endovascular stroke revascularization: A systematic review and meta-analysis

Key point:

    • To compare outcomes of stroke patients receiving GA and CS/local anesthesia during the procedure.

Despite recently published trials showed the sizeable treatment effect of the endovascular mechanical thrombectomy, several studies suggest that the choice of anesthetic management during the endovascular recanalization procedure may have a substantial effect on patient outcomes. Preliminary retrospective observational studies have suggested that general anesthesia (GA) is associated with poorer outcomes than conscious sedation (CS)/local anesthesia, while recently published randomized controlled trials shows no difference in successful recanalization or neurological outcome. In this paper, published online September, 2017, on Stroke, Authors performed a meta-analysis of studies comparing outcomes of stroke patients receiving GA and CS/local anesthesia during the procedure, including 22 articles with 4716 patients (1819 GA and 2897 non-GA). Baseline cohort characteristics are reported in the following table.

Baseline characteristics

Participants Sex (%) Age (years) Hypertension (%) Smokers (%)
Ga 48.5 65.5 y (57-78) 68.4 28.3
non-Ga 49 67 y (62-73) 63.6 26.3

This meta-analysis showed that patients who received GA had lower rates of good functional outcome (mRs≤2; OR, 0.58; 95% confidence interval [CI], 0.48–0.64), higher rates of 90-days mortality (OR, 2.02; 95% CI, 1.66–2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22–2.37) than patients who received CS. No difference in recanalization rates (OR, 1.04; 95% CI, 0.83–1.31) or vascular complications(OR, 1.43; 95% CI, 1.01–2.03) were found.

Authors also analyzed factors that might be associated with poorer neurological outcomes:

Factors analysis
  • Delay of treatment: door-to-groin puncture times were ≈16 minutes longer for the GA group than the non-GA group.
  • Hemodynamic effects: in most studies, intra-operative blood pressure during thrombectomy was lower with GA than CS and it was shown that pharmacologically induced decrease in blood pressure exceeding 20 to 30 mmHg in the acute phase of stroke is associated with less favorable outcomes.
  • Procedure time: the main factor favoring GA. In fact, in the SIESTA trial patients undergoing GA had a 10% higher recanalization rate than non-GA patients, with a significantly shorter procedure times. But the problem is that many centers do not have highly specialized anesthesia/neurocritical care team for stroke interventions.

In conclusion:

  • Despite this meta-analysis showed that acute stroke patients receiving GA had significantly higher rates of morbidity and mortality compared with non-GA patients, the majority of published studies are not randomized trials. For this reason, additional randomized controlled trials are needed.

Reference

  • Waleed Brinjikji, Jeffrey Pasternak, Mohammad H. Murad, Harry J. Cloft, Tasha L. Welch, David F. Kallmes, Alejandro A. Rabinstein. Anesthesia-related outcomes for endovascular stroke revascularization: a systematic review and meta-analysis. Stroke. 2017 Sep 13. pii: STROKEAHA.117.017786. doi: 10.1161/STROKEAHA.117.017786. [Epub ahead of print]

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