Association of General Anesthesia vs Procedural Sedation With Functional Outcome Among Patients With Acute Ischemic Stroke Undergoing Thrombectomy: A Systematic Review and Meta-analysis

Abstract

Importance: General anesthesia during thrombectomy for acute ischemic stroke has been associated with poor neurological outcome in nonrandomized studies. Three single-center randomized trials reported no significantly different or improved outcomes for patients who received general anesthesia compared with procedural sedation.

Objective: To detect differences in functional outcome at 3 months between patients who received general anesthesia vs procedural sedation during thrombectomy for anterior circulation acute ischemic stroke.

Data source: MEDLINE search for English-language articles published from January 1, 1980, to July 31, 2019.

Study selection: Randomized clinical trials of adults with a National Institutes of Health Stroke Scale score of at least 10 and anterior circulation acute ischemic stroke assigned to receive general anesthesia or procedural sedation during thrombectomy.

Data extraction and synthesis: Individual patient data were obtained from 3 single-center, randomized, parallel-group, open-label treatment trials with blinded end point evaluation that met inclusion criteria and were analyzed using fixed-effects meta-analysis.

Main outcomes and measures: Degree of disability, measured via the modified Rankin Scale (mRS) score (range 0-6; lower scores indicate less disability), analyzed with the common odds ratio (cOR) to detect the ordinal shift in the distribution of disability over the range of mRS scores.

Results: A total of 368 patients (mean [SD] age, 71.5 [12.9] years; 163 [44.3%] women; median [interquartile range] National Institutes of Health Stroke Scale score, 17 [14-21]) were included in the analysis, including 183 (49.7%) who received general anesthesia and 185 (50.3%) who received procedural sedation. The mean 3-month mRS score was 2.8 (95% CI, 2.5-3.1) in the general anesthesia group vs 3.2 (95% CI, 3.0-3.5) in the procedural sedation group (difference, 0.43 [95% CI, 0.03-0.83]; cOR, 1.58 [95% CI, 1.09-2.29]; P = .02). Among prespecified adverse events, only hypotension (decline in systolic blood pressure of more than 20% from baseline) (80.8% vs 53.1%; OR, 4.26 [95% CI, 2.55-7.09]; P < .001) and blood pressure variability (systolic blood pressure >180 mm Hg or <120 mm Hg) (79.7 vs 62.3%; OR, 2.42 [95% CI, 1.49-3.93]; P < .001) were significantly more common in the general anesthesia group.

Conclusions and relevance: Among patients with acute ischemic stroke involving the anterior circulation undergoing thrombectomy, the use of protocol-based general anesthesia, compared with procedural sedation, was significantly associated with less disability at 3 months. These findings should be interpreted tentatively, given that the individual trials examined were single-center trials and disability was the primary outcome in only 1 trial.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Simonsen reported receiving grants from Novo Nordisk Foundation during the conduct of the study and personal fees from Bayer and Pfizer outside the submitted work. Dr Pfaff reported receiving personal fees from Stryker and MircoVention outside the submitted work. Dr Yoo reported receiving grants from Neuravi, Penumbra, Cerenovus, Medtronic, Stryker, and Genentech and owns equity in Insera Therapeutics outside the submitted work. Dr Ringleb reported receiving personal fees from Boehringer Ingelheim, Bayer, Pfizer, Daiichi Sankyo, Covidien, and Bristol-Myers Squibb outside the submitted work. Dr Wick reported receiving research support from Appendix, Boehringer Ingelheim, Pfizer, Roche, and Vaximm. Dr Möhlenbruch reported receiving personal fees from Codman, MicroVention, Phenox, and Stryker outside the submitted work. Dr Rentzos reported receiving personal fees from Abbott Medical Sweden and I4L Innovation for Life outside the submitted work. Dr Rasmussen reported receiving a grant from the Health Research Foundation of Central Denmark Region. Dr Bösel reported receiving personal fees from Boehringer Ingelheim, Medtronic, and Zoll and support from an award from the Patient-Centered Outcomes Research Institute outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Functional Outcome at 90 Days for the Intention-to-Treat Population in a Study of the Association of General Anesthesia vs Procedural Sedation With Functional Outcome Among Patients With Acute Ischemic Stroke Undergoing Thrombectomy

The modified Rankin Scale (mRS) score ranges from 0-6, with 0 indicating no symptoms; 1, no clinically relevant disability; 2, slight disability (able to look after own affairs without assistance but not to full extent); 3, moderate disability (requires some help but able to walk unassisted); 4, moderately severe disability (requires assistance and unable to walk unassisted); 5, severe disability (requires constant nursing care); and 6, death. Each cell corresponds to a score on the modified Rankin Scale; the width of the cell indicates the proportion of patients with equivalent scores, and the percentage of patients is shown within the cell. Distribution of mRS categories was additionally tested using the Mann-Whitney U test (P = .41).

Figure 2.. Subgroup Analyses for the Primary Outcome for the Intention-to-Treat Population in a Study of the Association of General Anesthesia vs Procedural Sedation With Functional Outcome Among Patients With Acute Ischemic Stroke Undergoing Thrombectomy

Definitions of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and National Institutes of Health Stroke Scale (NIHSS) are included in the footnotes in Table 1. Size of the data markers is proportional to the precision of the estimates (ie, the area is proportional to the inverse of the squared standard errors). An interaction term between treatment group × the subgroup variable was included in the model (separately for each subgroup) to calculate P values. rtPA indicates recombinant tissue-type plasminogen activator.