General Anesthesia versus Sedation, Both with Hemodynamic Control, during Intraarterial Treatment for Stroke: The GASS Randomized Trial

Abstract

Background It is speculated that the anesthetic strategy during endovascular therapy for stroke may have an impact on the outcome of the patients. The authors hypothesized that conscious sedation is associated with a better functional outcome 3 months after endovascular therapy for the treatment of stroke compared with general anesthesia. Methods In this single-blind, randomized trial, patients received either a standardized general anesthesia or a standardized conscious sedation. Blood pressure control was also standardized in both groups. The primary outcome measure was a modified Rankin score less than or equal to 2 (0 = no symptoms; 5 = severe disability) assessed 3 months after treatment. The main secondary outcomes were complications, mortality, reperfusion results, and National Institutes of Health Stroke Scores at days 1 and 7. Results Of 351 randomized patients, 345 were included in the analysis. The primary outcome occurred in 129 of 341 (38%) of the patients: 63 (36%) in the conscious sedation group and 66 (40%) in the general anesthesia group (relative risk, 0.91 [95% CI, 0.69 to 1.19]; P = 0.474). Patients in the general anesthesia group experienced more intraoperative hypo- or hypertensive episodes, while the cumulative duration was not different (mean ± SD, 36 ± 31 vs. 39 ± 25 min; P = 0.079). The time from onset and from arrival to puncture were longer in the general anesthesia group (mean difference, 19 min [i.e., −00:19] [95% CI, −0:38 to 0] and mean difference, 9 min [95% CI, −0:18 to −0:01], respectively), while the time from onset to recanalization was similar in both groups. Recanalization was more often successful in the general anesthesia group (144 of 169 [85%] vs. 131 of 174 [75%]; P = 0.021). The incidence of symptomatic intracranial hemorrhage was similar in both groups. Conclusions The functional outcomes 3 months after endovascular treatment for stroke were similar with general anesthesia and sedation. Our results, therefore, suggest that clinicians can use either approach. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

General anesthesia but not conscious sedation improves functional outcome in patients receiving endovascular thrombectomy for acute ischemic stroke: A meta-analysis of randomized clinical trials and trial sequence analysis

“…Figure 1 shows the various reasons for study exclusion after full-text screening. Finally, six RCTs involving 883 patients undergoing EVT published from 2016 to 2022 were included in this meta-analysis (14)(15)(16)(17)(18)(19). Study characteristics are described in Table 1.…”

“…The median or mean age of the participants ranged from 60 to 73 years with a proportion of male gender being 44-66%. The six studies that provided details regarding the baseline NIHSS score (range: 13-20) all reported no difference between the GA and CS groups (14)(15)(16)(17)(18)(19). The sample size of individual RCT varied between 40 and 345.…”

“…The reasons for conversion are demonstrated in Supplementary Table 2, revealing that patient agitation was the most common reason for conversion. In the GA group, anesthetic agents for maintenance of anesthesia included sevoflurane (one study) (15) and propofol (four studies) (16)(17)(18)(19) with the use of remifentanil, while one study did not provide relevant details (14). In the CS group, propofol with or without short-acting opioids was used in the three studies (16)(17)(18).…”

Fokus Neurologische Intensivmedizin 2021/2022

“…In einer multizentrischen randomisierten Studie untersuchten nun Maurice et al. und das „French Society of Anesthesiologists Research Network“ [ 8 ] die Effekte der Allgemeinanästhesie im Vergleich zur alleinigen Sedierung bei Patientinnen und Patienten, die aufgrund eines Hirninfarktes bei zugrunde liegendem proximalen Gefäßverschluss eine endovaskuläre Therapie erhielten. Die Studie rekrutierte in 4 Zentren in Frankreich und konnte 351 Betroffene einschließen.…”

“…In dieser ersten multizentrischen randomisierten Studie von Maurice et al. [ 8 ] waren die Allgemeinanästhesie und die alleinige Sedierung mit dem gleichen Behandlungsergebnis, bezogen auf den Grad der funktionellen Beeinträchtigung nach 3 Monaten, assoziiert. Die Überlegenheit eines dieser beiden Verfahren lässt sich somit nicht ableiten.…”