Anesthesia for endovascular treatment in anterior circulation stroke: A systematic review and meta‐analysis

Abstract

BackgroundEndovascular treatment in patients with acute anterior circulation stroke could be performed under either conscious sedation (CS) or general anesthesia (GA). Although several studies have investigated the association between the clinical outcomes and the two anesthesia methods, consensus is lacking.MethodsPubMed and EMBASE searches were used to select full‐text articles comparing the effects of GA and CS on functional outcome and complications in patients with anterior circulation ischemic stroke. Enrolled patients were assigned to receive endovascular treatment with CS or GA, with a primary outcome of functional independency within 90 days. Secondary outcomes included intracranial hemorrhage, all‐cause mortality at 90 days, pneumonia, and intraprocedural complications.ResultsThirteen studies (3 RCTs and 10 observational studies), which included 3,857 patients (CS = 2,129, GA = 1,728), were eligible for the analysis. The overall analysis including the RCTs and observational studies demonstrated that the functional independence within 90 days occurred more frequently among patients with CS compared with GA (OR, 1.42; 95% CI, 1.05–1.92, p = 0.02); and the risk of mortality was higher with GA compared with CS; furthermore, CS was associated with lower rate of intracranial hemorrhage. In RCTs, GA was associated with increased functional independence (OR, 0.55; 95% CI, 0.34–0.89, p = 0.01) and successful reperfusion (OR, 0.51; 95% CI, 0.30–0.89, p = 0.02).ConclusionsIn the overall analysis and observational studies, CS was associated with improved functional outcomes and relatively safe for anterior ischemic stroke compared with GA. While the pooled data from RCTs suggested that GA was associated with improved outcomes. The inconsistency indicated that more large‐scale RCTs are required to evaluate what factors influenced the effect of the anesthesia methods on clinical outcomes.

Influence of Anesthesia Type on Outcomes after Endovascular Treatment in Acute Ischemic Stroke: Meta-Analysis

“…However, only for RCTs, GA was associated with improved functional outcomes. 33 In our initial analysis, GA showed lower good outcomes (OR, 0.564; 95% CI, 0.354-0.899). But, the funnel plot was slightly asymmetric, indicating possible publication bias.…”

“…Regarding successful recanalization, anesthesia type did not affect outcomes in acute stroke patients who underwent mechanical thrombectomy only (OR, 0.831; 95% CI, 0.616–1.122). Li et al [ 33 ] investigated anesthesia effect on clinical outcomes in patients with anterior circulation stroke and reported inconsistent results. CS was related to improved outcome.…”

“…CS was related to improved outcome. However, only for RCTs, GA was associated with improved functional outcomes [ 33 ]. In our initial analysis, GA showed lower good outcomes (OR, 0.564; 95% CI, 0.354–0.899).…”

Endovascular Treatment for Acute Ischemic Stroke With or Without General Anesthesia: A Matched Comparison

“…Our main finding is in line with several observational studies, [3][4][5][6][7][8][9][10][11][12][13][14]32,33 systematic reviews, and meta-analyses. [34][35][36][37][38][39][40][41] In particular, the 2 largest single studies to date, a meta-analysis of individual patient data from 1764 patients receiving EVT in RCTs by the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration, and 2 registry cohort studies from Italy and Germany of EVT in acute stroke with 4429 and 5808 patients, respectively, showed a worse functional outcome after EVT under GA compared with non-GA. 32,33,36 Recently, GA versus conscious sedation versus local anesthesia alone were compared among 1376 patients in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) registry yielding best functional outcome with local anesthesia. 42 Five RCTs of limited size have compared outcomes after EVT with versus without GA: The AnStroke trial (Anesthesia During Stroke) reported no difference in 3 months mRS between GA and non-GA in 90 patients.…”