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Original Investigation
October 1, 2019

Association of General Anesthesia vs Procedural Sedation With Functional Outcome Among Patients With Acute Ischemic Stroke Undergoing Thrombectomy: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
  • 2Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
  • 3Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
  • 4Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
  • 5Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
  • 6Department of Radiology, Neuroendovascular Service, Texas Stroke Institute, Fort Worth
  • 7Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
  • 8German Cancer Consortium (DKTK), German Cancer Research Center, Heidelberg, Germany
  • 9Department of Anesthesia, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
  • 10Department of Radiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
  • 11Department of Neurology, Klinikum Kassel, Kassel, Germany
JAMA. 2019;322(13):1283-1293. doi:10.1001/jama.2019.11455
Key Points

Question  Is there a difference in functional outcome at 3 months between patients who receive general anesthesia or procedural sedation during stroke thrombectomy?

Findings  In this individual patient data meta-analysis of 3 randomized clinical trials that included 368 patients with acute ischemic stroke in the anterior circulation, the use of general anesthesia during thrombectomy, compared with procedural sedation, was significantly associated with less disability at 3 months (common odds ratio for categorical shift in the modified Rankin Scale score, 1.58).

Meaning  General anesthesia during thrombectomy, compared with procedural sedation, was associated with less disability at 3 months after ischemic stroke, although the findings should be interpreted tentatively because the individual trials analyzed were single-center trials and disability was the primary outcome in only 1 trial.

Abstract

Importance  General anesthesia during thrombectomy for acute ischemic stroke has been associated with poor neurological outcome in nonrandomized studies. Three single-center randomized trials reported no significantly different or improved outcomes for patients who received general anesthesia compared with procedural sedation.

Objective  To detect differences in functional outcome at 3 months between patients who received general anesthesia vs procedural sedation during thrombectomy for anterior circulation acute ischemic stroke.

Data Source  MEDLINE search for English-language articles published from January 1, 1980, to July 31, 2019.

Study Selection  Randomized clinical trials of adults with a National Institutes of Health Stroke Scale score of at least 10 and anterior circulation acute ischemic stroke assigned to receive general anesthesia or procedural sedation during thrombectomy.

Data Extraction and Synthesis  Individual patient data were obtained from 3 single-center, randomized, parallel-group, open-label treatment trials with blinded end point evaluation that met inclusion criteria and were analyzed using fixed-effects meta-analysis.

Main Outcomes and Measures  Degree of disability, measured via the modified Rankin Scale (mRS) score (range 0-6; lower scores indicate less disability), analyzed with the common odds ratio (cOR) to detect the ordinal shift in the distribution of disability over the range of mRS scores.

Results  A total of 368 patients (mean [SD] age, 71.5 [12.9] years; 163 [44.3%] women; median [interquartile range] National Institutes of Health Stroke Scale score, 17 [14-21]) were included in the analysis, including 183 (49.7%) who received general anesthesia and 185 (50.3%) who received procedural sedation. The mean 3-month mRS score was 2.8 (95% CI, 2.5-3.1) in the general anesthesia group vs 3.2 (95% CI, 3.0-3.5) in the procedural sedation group (difference, 0.43 [95% CI, 0.03-0.83]; cOR, 1.58 [95% CI, 1.09-2.29]; P = .02). Among prespecified adverse events, only hypotension (decline in systolic blood pressure of more than 20% from baseline) (80.8% vs 53.1%; OR, 4.26 [95% CI, 2.55-7.09]; P < .001) and blood pressure variability (systolic blood pressure >180 mm Hg or <120 mm Hg) (79.7 vs 62.3%; OR, 2.42 [95% CI, 1.49-3.93]; P < .001) were significantly more common in the general anesthesia group.

Conclusions and Relevance  Among patients with acute ischemic stroke involving the anterior circulation undergoing thrombectomy, the use of protocol-based general anesthesia, compared with procedural sedation, was significantly associated with less disability at 3 months. These findings should be interpreted tentatively, given that the individual trials examined were single-center trials and disability was the primary outcome in only 1 trial.

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