A Second Randomized Trial Comparing General Anesthesia to Conscious Sedation in Acute Ischemic Stroke Patients Undergoing Endovascular Treatment

A Second Randomized Trial Comparing General Anesthesia to Conscious Sedation in Acute Ischemic... Endovascular therapy has become the standard of care for patients with ischemic stroke due to acute large vessel occlusions.1 For a variety of reasons, such as compromised mental status and interfacility transfer, these patients are commonly intubated prior to or upon reaching the neurointerventional suite. Yet multiple retrospective studies2 and also a post hoc analysis of the MR CLEAN trial3 have suggested that conscious sedation (CS) leads to better clinical outcomes than general anesthesia (GA) in these patients. Recently, the Sedation versus Intubation for Endovascular Stroke Treatment (SIESTA) trial4 was the first randomized study to compare CS with GA in stroke thrombectomy, and it did not confirm the superiority of CS. The Anesthesia During Stroke (AnStroke) trial further investigated this question.5 The AnStroke investigators studied patients with radiographically confirmed anterior circulation large vessel occlusions who presented within 8 h of symptom onset. They randomized patients to either GA, performed with propofol and remifentanil for induction and sevoflurane and remifentanil for maintenance, or CS, performed with remifentanil infusion only. They measured systolic, diastolic, and mean arterial blood pressures (MAP) prior to GA or CS and then again every 5 min throughout the procedure and used vasoactive medications at the discretion of the attending anesthesiologist to aim for a systolic blood pressure goal of 140 to 180 mm Hg. They calculated multiple clinical time metrics throughout the treatment process (eg, time from groin puncture to recanalization) and measured clinical outcomes using the National Institutes of Health Stroke Scale and the modified Rankin score (mRS), with the primary outcome measure being mRS at 3 mo post stroke. Ultimately, 46 patients received GA and 45 patients received CS but 7 of the CS patients (16%) were subsequently converted to GA due to various indications (loss of airway, requirement for direct carotid puncture, extensive patient movement). There was no significant difference between the GA and CS groups in any of the clinical time metrics (Table). Not unexpectedly, the GA cohort was more likely to experience transient hypotension (ie, >20% fall from baseline MAP) and to receive vasoactive medications than the CS cohort, but was not more likely to experience profound transient hypotension (>40% fall in MAP). Furthermore, the averaged MAP throughout the duration of the procedure did not differ between the 2 groups (P = .57). There were no significant differences found between the GA and CS groups in short or long-term clinical outcomes or in periprocedural complication rates. The authors conclude that, so long as profound hypotension is avoided, CS is not superior to GA in endovascular stroke patients. This study's findings are similar to those seen in the SIESTA trial. However, both of these studies suffer from serious limitations. The trials were both small, and it is unclear if they were adequately powered to show a meaningful difference in outcome. They were performed at single centers with dedicated neuroanesthesiology teams, and these conditions may not be generalizable to many other centers without dedicated anesthesia teams who may take longer to induce anesthesia and who may not manage hypotension as carefully or rapidly. If a patient cannot protect their airway, then endotracheal intubation is obviously warranted. But if a patient can protect their airway, arguments in favor of GA are limited. It has been suggested, for example, that GA patients may have lower rates of vascular complications like vessel perforation due to less patient movement. Yet the data simply do not suggest that CS patients have higher rates of vascular complications than GA patients,2 and the highest quality meta-analysis data available (combining both retrospective and randomized studies) suggests that GA patients may have lower rates of good functional outcome and higher rates of mortality and respiratory complications when compared to CS patients.2 TABLE. Intraoperative Variables for the General Anesthesia and Conscious Sedation Cohorts Including Time Intervals, Hemodynamic, and Respiratory Data   GA  CS      n = 45  n = 45  P value  Time intervals, min         From stroke onset to CT  97 (62-160)  72 (58-119)  .2523   From stroke onset to groin puncture  183 (135-279)  180 (137-252)  .6141   From stroke onset to recanalization/end of procedure  254 (206-373)  250 (213-316)  .7833   From CT to groin puncture  92 (68-121)  91 (55-123)  .9376   From CT to recanalization/end of procedure  153 (113-223)  175 (126-206)  .6747   From arrival to neurointerventional suite to groin puncture  34 (18-47)  25 (15-36)  .0555   From groin puncture to recanlization/end of procedure  55 (38-110)  74 (37-104)  .6572  Hemodynamic and respiratory data         Baseline MAP before induction of anesthesia, mm Hg  105 ± 16  108 ± 17  .4086   Blood pressure intraoperative          MAP, mm Hg  91 ± 8  95 ± 11  .0484    MAP, fraction of baseline MAP  0.88 ± 0.10  0.89 ± 0.90  .5678    Highest MAP, mm Hg  116 ± 15  114 ± 15  .5631    Lowest MAP, mm Hg  68 ± 12  77 ± 15  .0015    Lowest MAP, fraction of baseline MAP  0.65 ± 0.11  0.72 ± 0.15  .0125    Occurrence of >20% fall in MAP compared with baseline MAP, n (%)  41 (93)  26 (60)  .0003    Time spent with >20% fall in MAP compared with baseline MAP, min  22 (5-57)  15 (0-55)  .0432   Occurrence of >40% fall in MAP compared with baseline, n (%)  15 (34)  9 (21)  .2311    Time spent with >40% fall in MAP compared with baseline, min  0 (0-9)  0 (0-0)  .1167   Use of vasoactive drugs, n (%)  43 (98)  34 (79)  .0073   Pao2, kPa  17.2 (11.6-25.1)  11.2 (9.7-14.7)  <.0001   Hemoglobin oxygen saturation, %  98 ± 1  96 ± 2  <.0001   Hemoglobin concentration, g/L  128 ± 14  131 ± 17  .4488   PaCo2, kPa  5.4 (4.8-5.9)  5.2 (4.6-6.0)  .5732   Blood glucose, mmol/L  7.0 (6.2-8.5)  6.9 (6.2-8.1)  .8014    GA  CS      n = 45  n = 45  P value  Time intervals, min         From stroke onset to CT  97 (62-160)  72 (58-119)  .2523   From stroke onset to groin puncture  183 (135-279)  180 (137-252)  .6141   From stroke onset to recanalization/end of procedure  254 (206-373)  250 (213-316)  .7833   From CT to groin puncture  92 (68-121)  91 (55-123)  .9376   From CT to recanalization/end of procedure  153 (113-223)  175 (126-206)  .6747   From arrival to neurointerventional suite to groin puncture  34 (18-47)  25 (15-36)  .0555   From groin puncture to recanlization/end of procedure  55 (38-110)  74 (37-104)  .6572  Hemodynamic and respiratory data         Baseline MAP before induction of anesthesia, mm Hg  105 ± 16  108 ± 17  .4086   Blood pressure intraoperative          MAP, mm Hg  91 ± 8  95 ± 11  .0484    MAP, fraction of baseline MAP  0.88 ± 0.10  0.89 ± 0.90  .5678    Highest MAP, mm Hg  116 ± 15  114 ± 15  .5631    Lowest MAP, mm Hg  68 ± 12  77 ± 15  .0015    Lowest MAP, fraction of baseline MAP  0.65 ± 0.11  0.72 ± 0.15  .0125    Occurrence of >20% fall in MAP compared with baseline MAP, n (%)  41 (93)  26 (60)  .0003    Time spent with >20% fall in MAP compared with baseline MAP, min  22 (5-57)  15 (0-55)  .0432   Occurrence of >40% fall in MAP compared with baseline, n (%)  15 (34)  9 (21)  .2311    Time spent with >40% fall in MAP compared with baseline, min  0 (0-9)  0 (0-0)  .1167   Use of vasoactive drugs, n (%)  43 (98)  34 (79)  .0073   Pao2, kPa  17.2 (11.6-25.1)  11.2 (9.7-14.7)  <.0001   Hemoglobin oxygen saturation, %  98 ± 1  96 ± 2  <.0001   Hemoglobin concentration, g/L  128 ± 14  131 ± 17  .4488   PaCo2, kPa  5.4 (4.8-5.9)  5.2 (4.6-6.0)  .5732   Blood glucose, mmol/L  7.0 (6.2-8.5)  6.9 (6.2-8.1)  .8014  GA, general anesthesia; CS, conscious sedation; MAP, mean arterial pressure. Reprinted with permission from Henden et al.5 View Large The authors are to be commended for this research that aims to optimize the anesthetic management strategy for endovascular stroke patients and by doing so improve neurological outcomes. However, larger multiinstitutional randomized trials will be needed to meaningfully answer this question. REFERENCES 1. Goyal M, Menon BK, Van zwam WH et al.   Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet . 2016; 387( 10029): 1723- 1731. Google Scholar CrossRef Search ADS PubMed  2. Brinjikji W, Pasternak J, Murad MH et al.   Anesthesia-related outcomes for endovascular stroke revascularization. Stroke . 2017; 48( 10): 2784- 2791. Google Scholar CrossRef Search ADS PubMed  3. Berkhemer OA, Van den berg LA, Fransen PS et al.   The effect of anesthetic management during intra-arterial therapy for acute stroke in MR CLEAN. Neurology . 2016; 87( 7): 656- 664. Google Scholar CrossRef Search ADS PubMed  4. Schönenberger S, Uhlmann L, Hacke W et al.   Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy. JAMA . 2016; 316( 19): 1986- 1996. Google Scholar CrossRef Search ADS PubMed  5. Löwhagen hendén P, Rentzos A, Karlsson JE et al.   General anesthesia versus conscious sedation for endovascular treatment of acute ischemic stroke. Stroke . 2017; 48( 6): 1601- 1607. Google Scholar CrossRef Search ADS PubMed  Copyright © 2017 by the Congress of Neurological Surgeons http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

A Second Randomized Trial Comparing General Anesthesia to Conscious Sedation in Acute Ischemic Stroke Patients Undergoing Endovascular Treatment

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Congress of Neurological Surgeons
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Copyright © 2017 by the Congress of Neurological Surgeons
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0148-396X
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10.1093/neuros/nyx589
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Abstract

Endovascular therapy has become the standard of care for patients with ischemic stroke due to acute large vessel occlusions.1 For a variety of reasons, such as compromised mental status and interfacility transfer, these patients are commonly intubated prior to or upon reaching the neurointerventional suite. Yet multiple retrospective studies2 and also a post hoc analysis of the MR CLEAN trial3 have suggested that conscious sedation (CS) leads to better clinical outcomes than general anesthesia (GA) in these patients. Recently, the Sedation versus Intubation for Endovascular Stroke Treatment (SIESTA) trial4 was the first randomized study to compare CS with GA in stroke thrombectomy, and it did not confirm the superiority of CS. The Anesthesia During Stroke (AnStroke) trial further investigated this question.5 The AnStroke investigators studied patients with radiographically confirmed anterior circulation large vessel occlusions who presented within 8 h of symptom onset. They randomized patients to either GA, performed with propofol and remifentanil for induction and sevoflurane and remifentanil for maintenance, or CS, performed with remifentanil infusion only. They measured systolic, diastolic, and mean arterial blood pressures (MAP) prior to GA or CS and then again every 5 min throughout the procedure and used vasoactive medications at the discretion of the attending anesthesiologist to aim for a systolic blood pressure goal of 140 to 180 mm Hg. They calculated multiple clinical time metrics throughout the treatment process (eg, time from groin puncture to recanalization) and measured clinical outcomes using the National Institutes of Health Stroke Scale and the modified Rankin score (mRS), with the primary outcome measure being mRS at 3 mo post stroke. Ultimately, 46 patients received GA and 45 patients received CS but 7 of the CS patients (16%) were subsequently converted to GA due to various indications (loss of airway, requirement for direct carotid puncture, extensive patient movement). There was no significant difference between the GA and CS groups in any of the clinical time metrics (Table). Not unexpectedly, the GA cohort was more likely to experience transient hypotension (ie, >20% fall from baseline MAP) and to receive vasoactive medications than the CS cohort, but was not more likely to experience profound transient hypotension (>40% fall in MAP). Furthermore, the averaged MAP throughout the duration of the procedure did not differ between the 2 groups (P = .57). There were no significant differences found between the GA and CS groups in short or long-term clinical outcomes or in periprocedural complication rates. The authors conclude that, so long as profound hypotension is avoided, CS is not superior to GA in endovascular stroke patients. This study's findings are similar to those seen in the SIESTA trial. However, both of these studies suffer from serious limitations. The trials were both small, and it is unclear if they were adequately powered to show a meaningful difference in outcome. They were performed at single centers with dedicated neuroanesthesiology teams, and these conditions may not be generalizable to many other centers without dedicated anesthesia teams who may take longer to induce anesthesia and who may not manage hypotension as carefully or rapidly. If a patient cannot protect their airway, then endotracheal intubation is obviously warranted. But if a patient can protect their airway, arguments in favor of GA are limited. It has been suggested, for example, that GA patients may have lower rates of vascular complications like vessel perforation due to less patient movement. Yet the data simply do not suggest that CS patients have higher rates of vascular complications than GA patients,2 and the highest quality meta-analysis data available (combining both retrospective and randomized studies) suggests that GA patients may have lower rates of good functional outcome and higher rates of mortality and respiratory complications when compared to CS patients.2 TABLE. Intraoperative Variables for the General Anesthesia and Conscious Sedation Cohorts Including Time Intervals, Hemodynamic, and Respiratory Data   GA  CS      n = 45  n = 45  P value  Time intervals, min         From stroke onset to CT  97 (62-160)  72 (58-119)  .2523   From stroke onset to groin puncture  183 (135-279)  180 (137-252)  .6141   From stroke onset to recanalization/end of procedure  254 (206-373)  250 (213-316)  .7833   From CT to groin puncture  92 (68-121)  91 (55-123)  .9376   From CT to recanalization/end of procedure  153 (113-223)  175 (126-206)  .6747   From arrival to neurointerventional suite to groin puncture  34 (18-47)  25 (15-36)  .0555   From groin puncture to recanlization/end of procedure  55 (38-110)  74 (37-104)  .6572  Hemodynamic and respiratory data         Baseline MAP before induction of anesthesia, mm Hg  105 ± 16  108 ± 17  .4086   Blood pressure intraoperative          MAP, mm Hg  91 ± 8  95 ± 11  .0484    MAP, fraction of baseline MAP  0.88 ± 0.10  0.89 ± 0.90  .5678    Highest MAP, mm Hg  116 ± 15  114 ± 15  .5631    Lowest MAP, mm Hg  68 ± 12  77 ± 15  .0015    Lowest MAP, fraction of baseline MAP  0.65 ± 0.11  0.72 ± 0.15  .0125    Occurrence of >20% fall in MAP compared with baseline MAP, n (%)  41 (93)  26 (60)  .0003    Time spent with >20% fall in MAP compared with baseline MAP, min  22 (5-57)  15 (0-55)  .0432   Occurrence of >40% fall in MAP compared with baseline, n (%)  15 (34)  9 (21)  .2311    Time spent with >40% fall in MAP compared with baseline, min  0 (0-9)  0 (0-0)  .1167   Use of vasoactive drugs, n (%)  43 (98)  34 (79)  .0073   Pao2, kPa  17.2 (11.6-25.1)  11.2 (9.7-14.7)  <.0001   Hemoglobin oxygen saturation, %  98 ± 1  96 ± 2  <.0001   Hemoglobin concentration, g/L  128 ± 14  131 ± 17  .4488   PaCo2, kPa  5.4 (4.8-5.9)  5.2 (4.6-6.0)  .5732   Blood glucose, mmol/L  7.0 (6.2-8.5)  6.9 (6.2-8.1)  .8014    GA  CS      n = 45  n = 45  P value  Time intervals, min         From stroke onset to CT  97 (62-160)  72 (58-119)  .2523   From stroke onset to groin puncture  183 (135-279)  180 (137-252)  .6141   From stroke onset to recanalization/end of procedure  254 (206-373)  250 (213-316)  .7833   From CT to groin puncture  92 (68-121)  91 (55-123)  .9376   From CT to recanalization/end of procedure  153 (113-223)  175 (126-206)  .6747   From arrival to neurointerventional suite to groin puncture  34 (18-47)  25 (15-36)  .0555   From groin puncture to recanlization/end of procedure  55 (38-110)  74 (37-104)  .6572  Hemodynamic and respiratory data         Baseline MAP before induction of anesthesia, mm Hg  105 ± 16  108 ± 17  .4086   Blood pressure intraoperative          MAP, mm Hg  91 ± 8  95 ± 11  .0484    MAP, fraction of baseline MAP  0.88 ± 0.10  0.89 ± 0.90  .5678    Highest MAP, mm Hg  116 ± 15  114 ± 15  .5631    Lowest MAP, mm Hg  68 ± 12  77 ± 15  .0015    Lowest MAP, fraction of baseline MAP  0.65 ± 0.11  0.72 ± 0.15  .0125    Occurrence of >20% fall in MAP compared with baseline MAP, n (%)  41 (93)  26 (60)  .0003    Time spent with >20% fall in MAP compared with baseline MAP, min  22 (5-57)  15 (0-55)  .0432   Occurrence of >40% fall in MAP compared with baseline, n (%)  15 (34)  9 (21)  .2311    Time spent with >40% fall in MAP compared with baseline, min  0 (0-9)  0 (0-0)  .1167   Use of vasoactive drugs, n (%)  43 (98)  34 (79)  .0073   Pao2, kPa  17.2 (11.6-25.1)  11.2 (9.7-14.7)  <.0001   Hemoglobin oxygen saturation, %  98 ± 1  96 ± 2  <.0001   Hemoglobin concentration, g/L  128 ± 14  131 ± 17  .4488   PaCo2, kPa  5.4 (4.8-5.9)  5.2 (4.6-6.0)  .5732   Blood glucose, mmol/L  7.0 (6.2-8.5)  6.9 (6.2-8.1)  .8014  GA, general anesthesia; CS, conscious sedation; MAP, mean arterial pressure. Reprinted with permission from Henden et al.5 View Large The authors are to be commended for this research that aims to optimize the anesthetic management strategy for endovascular stroke patients and by doing so improve neurological outcomes. However, larger multiinstitutional randomized trials will be needed to meaningfully answer this question. REFERENCES 1. Goyal M, Menon BK, Van zwam WH et al.   Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet . 2016; 387( 10029): 1723- 1731. Google Scholar CrossRef Search ADS PubMed  2. Brinjikji W, Pasternak J, Murad MH et al.   Anesthesia-related outcomes for endovascular stroke revascularization. Stroke . 2017; 48( 10): 2784- 2791. Google Scholar CrossRef Search ADS PubMed  3. Berkhemer OA, Van den berg LA, Fransen PS et al.   The effect of anesthetic management during intra-arterial therapy for acute stroke in MR CLEAN. Neurology . 2016; 87( 7): 656- 664. Google Scholar CrossRef Search ADS PubMed  4. Schönenberger S, Uhlmann L, Hacke W et al.   Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy. JAMA . 2016; 316( 19): 1986- 1996. Google Scholar CrossRef Search ADS PubMed  5. Löwhagen hendén P, Rentzos A, Karlsson JE et al.   General anesthesia versus conscious sedation for endovascular treatment of acute ischemic stroke. Stroke . 2017; 48( 6): 1601- 1607. Google Scholar CrossRef Search ADS PubMed  Copyright © 2017 by the Congress of Neurological Surgeons

Journal

NeurosurgeryOxford University Press

Published: Mar 1, 2018

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