Approach tied to better functional outcome after ischemic stroke vs procedural sedation
General anesthesia during thrombectomy following ischemic stroke was linked with less disability at 3 months compared with procedural sedation, a systematic review and meta-analysis found.
Mean 3-month modified Rankin Scale (mRS) score was 3.2 (95% CI 3.0-3.5) in the procedural sedation cohort versus 2.8 (95% CI 2.5-3.1) in the general anesthesia group (common odds ratio 1.58, P=0.02), reported Julian Bösel, MD, of Klinikum Kassel in Germany, and colleagues in JAMA.
Among prespecified adverse events, only blood pressure variability as indicated by systolic blood pressure of >180 mm Hg or <120 mm Hg (79.7% vs 62.3%, OR 2.42, P<0.001) and hypotension as indicated by a decrease in systolic blood pressure of >20% from baseline (80.8% vs 53.1%, OR 4.26, P<0.001) were significantly more common among the general anesthesia cohort, they reported.
But the results should be interpreted tentatively as they are based on single-center trials, and disability was the primary outcome for only one trial, the authors emphasized.
Still, the results suggest that compared with procedural sedation, general anesthesia was tied to a more favorable functional outcome, and that it may be advantageous provided that strict anesthetic and hemodynamic protocols are in effect, and performed by nurses and clinicians trained for that particular setting, the researchers noted.
Meta-analyses and retrospective studies have suggested higher mortality and poorer functional outcome in patients who receive general anesthesia than those receiving procedural sedation, they noted. Differences in sedative agents such as dosage and type were suggested to be linked with differences in functional outcome, but those investigations were limited by selection bias, they added.
Other research has shown that general anesthesia for patients undergoing endovascular therapy for acute ischemic stroke did not make them worse off than if they received conscious sedation.
The authors searched for studies published from January 1980 to July 2019. Inclusion criteria for the current analysis were adult participants who were randomized to receive procedural sedation or general anesthesia during thrombectomy, with acute ischemic stroke in the anterior circulation and an NIH Stroke Scale score of ≥10, and decision for thrombectomy according to standardized in-hospital protocols and local protocols for neuroanesthesia and physiology targets.
Exclusion criteria were studies involving participants with acute ischemic stroke in the posterior circulation, additional intracerebral hemorrhage, and those with radiologic ambiguity concerning vessel occlusion and infarction.
A total of 368 patients (44.3% women; mean age 71.5) were included. Of those, 49.7% were assigned to receive general anesthesia while 50.3% were assigned to receive procedural sedation. Patients in both groups were from the SIESTA, ANSTROKE, and GOLIATH studies.
Limitations included the fact that the current meta-analysis involved only three randomized single center trials, which limited the power to access cross-center differences. There also was limited ethnic and racial diversity among the study cohorts across all three trials, as they enrolled predominantly white European patients. The prespecified primary outcomes were different for every trial, and the relatively small sizes of single trials, Bösel's group noted.
Another limitation was that the current definitions of procedural sedation and general anesthesia are heterogeneous, and allow for an array of measures and drugs that were only partially addressed in these trials, the researchers added.
"Further research is needed to identify clinical and radiologic factors that could predict when primary general anesthesia is necessary to reduce the number of emergency conversions from procedural sedation to general anesthesia," the author concluded.
Taking into consideration the likelihood that the anesthetic methods and patient population assessed in the analysis differ from those in other countries, a multicenter, randomized controlled trial with at least a basic agreement on physiology parameter targets and standards of procedure directed at functional outcome after 3 months is needed, they added.
Last Updated October 02, 2019
Bösel disclosed relevant relationships with the Patient-Centered Outcomes Research Institute, Zoll, Boehringer Ingelheim, and Medtronic. Co-authors disclosed multiple relevant relationships with industry.
Source Reference: Schönenberger S, et al "Association of general anesthesia vs procedural sedation with functional outcome among patients with acute ischemic stroke undergoing thrombectomy A systematic review and meta-analysis" JAMA 2019; DOI: 10.1001/jama.2019.11455.
Read the full article on Medpage Today: Less Disability Seen With General Anesthesia for Thrombectomy