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

Omer F Eker, Jeffrey L Saver, Mayank Goyal, Reza Jahan, Elad I Levy, Raul G Nogueira, Dileep R Yavagal, Alain Bonafé, SWIFT PRIME investigators, Omer F Eker, Jeffrey L Saver, Mayank Goyal, Reza Jahan, Elad I Levy, Raul G Nogueira, Dileep R Yavagal, Alain Bonafé, SWIFT PRIME investigators

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.

Keywords: acute ischemic stroke; blood pressure; conscious sedation; general anesthesia; mechanical thrombectomy.

Figures

Figure 1
Figure 1
Functional outcomes at 90 days, according to the score on the modified ranking scale. The figure shows the subgroup analyses of mRS shifts comparison between GA-policy patients versus control group (A) and CS-policy patients versus control group (B) in SWIFT PRIME trial. Shown are the 90 day scores on the modified ranking scale for the patients in the two treatment groups. Score range from 2 to 6, with 0 indicating no symptoms, 1 no clinically significant disability (able to carry out all usual activities, despite some symptoms), 2 slight disability (able to look after own affairs without assistance but unable to carry out all previous activities), 3 moderate disability (requires some help but able to walk unassisted), 4 moderately several disability (unable to attend to bodily needs without assistance and unable to walk unassisted), 5 severe disability (requires constant nursing care and attention, bedridden, and incontinent), and 6 death.

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