Impact of Anesthetic Management on Safety and Outcomes Following Mechanical Thrombectomy for Ischemic Stroke in SWIFT PRIME Cohort

Abstract

Background and purpose: The optimal anesthetic management of acute ischemic stroke patients during mechanical thrombectomy (MT) remains controversial. In this post-hoc analysis, we investigated the impact of anesthesia type on clinical outcomes in patients included in SWIFT PRIME trial.Methods: Ninety-seven patients treated with MT were included. Patients treated in centers with general anesthesia (GA) policy (n = 32) were compared with those treated in centers with conscious sedation (CS) policy (n = 65). Primary outcomes studied included times to treatment initiation (TTI), rates of successful recanalization (TICI 2b/3), and functional independence (mRS 0–2 at 90 days). Secondary outcomes were adverse events, lowest systolic and diastolic blood pressures (LSBP and LDBP) during MT. Univariate analysis and multivariate regression logistic modeling were conducted.Results: The GA-policy and CS-policy groups presented comparable TTI (94 ± 36 min vs. 102 ± 48 min; p = 0.44), rates of TICI 2b/3 recanalization (22/32 [68.8%] vs. 51/65 [78.5%]; p = 0.32). CS-policy was associated to higher rate of functional independence than GA-policy, but the difference was not significant (43/65 [66.2%] vs. 16/32 [50.0%]; p = 0.18). GA-policy patients had a higher rate of postoperative pneumonia (11/32 [34.4%] vs. 8/65 [12.3%]; p = 0.02) and lower LSBP (110 [30,160] mmHg vs. 119 [77,170] mmHg; p = 0.03) and LDBP (55 (15,75) mmHg vs. 67 [40,121]; p < 0.001). When corrected for differences in baseline characteristics, GA-policy was associated with lower rate of functional independence (OR 0.32; p = 0.05). A 10-point increase in perprocedural LDBP was associated with an increased likelihood of favorable outcome (OR 1.51; p = 0.01).Conclusions: GA-policy for MT presented comparable TTI and rates of successful revascularization to CS-policy. However, GA-policy was associated with lower rates of functional independence and with higher incidence of perprocedural hypotension and postoperative pneumonia.Clinical Trial Registration: URL—http://www.clinicaltrials.gov. Unique identifier: NCT01657461

Pneumonia in Acute Ischemic Stroke Patients with Proximal Occlusions within the Anterior Circulation after Endovascular Therapy or Systemic Thrombolysis

“…As expected, and in good agreement with several previous reports, mechanical ventilation was also significantly associated with the risk of pneumonia in our cohort in both treatment groups [23,24]. Against the background of this increased risk, there is an ongoing discussion as to whether ET should be performed under conscious sedation or general anesthesia [24].…”

Effect of Conscious Sedation vs. General Anesthesia on Outcomes in Patients Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke: A Prospective Randomized Clinical Trial

“…However, functional outcomes and mortality rate at discharge and 3 months after stroke were comparable between the two groups. The reason may be due to the fewer DBP fluctuations in our study (45). A meta-analysis also suggested that close monitoring and strictly controlling hemodynamics seem more important regardless of the choice of agents and anesthetic technique (21).…”

Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

“…Since all patients in both groups were under general anesthesia during the intervention and we investigated the recanalization itself, we did not analyze anesthesiologic medication or blood pressure during the intervention. In literature, there is evidence for anesthesiologic management influencing outcome, but not recanalization results [36][37][38][39].…”