乌鸦传媒

Carefully selected vertebrobasilar occlusion stroke patients fared no worse with conscious sedation in lieu of general anesthesia during endovascular therapy, a retrospective study suggests.

The distribution of modified Rankin scale scores at 90 days was similar between recipients of monitored anesthesia care and their peers getting intubation (OR 1.52, 95% CI 0.80-2.90). The lack of difference held up after multivariable adjustment (OR 1.37, 95% CI 0.71-2.63) and multivariate conditional logistic regression (OR 1.60, 95% CI 0.73-3.53), according to Raul G. Nogueira, MD, of Emory University School of Medicine in Atlanta, and colleagues.

Deaths during the same period weren't statistically different between groups either (35% for conscious sedation versus 42.6% for elective general anesthesia, P=0.33).

"Historically, some clinicians feared that patient movement during conscious sedation would increase periprocedural complications, such as hemorrhage, and delay or prevent recanalization by compromising digital subtraction imaging. Moreover, vertebrobasilar occlusion strokes may lead to bulbar weakness and/or depressed level of consciousness with concerns for clearing oral secretions and airway protection," the authors explained in their report, published online in .

"Conversely, the routine application of general anesthesia may be harmful in a subset of patients because it may lead to decreased blood pressure and delays in achieving reperfusion."

"The remains, to our knowledge, the only randomized clinical study to evaluate the effect of anesthesia modality on clinical outcomes of patients undergoing endovascular therapy. While SIESTA provided strong evidence that general anesthesia and monitored anesthesia care are comparable, it only included patients with anterior circulation strokes," Nogueira's group recalled.

Moreover, they noted, patients with vertebrobasilar occlusion strokes have mostly been excluded from other studies.

The present analysis was a retrospective case-control study of 215 consecutive patients at two academic centers, 39 of whom were excluded because of emergent pre-endovascular therapy intubation. Patients were treated in the 2005-2015 period.

Primary analysis was performed on 122 propensity-matched patients. Baseline characteristics were well-balanced and neither group had more deaths and complications from endovascular therapy. Rates of recanalization and procedure times were also comparable between the conscious sedation and general anesthesia arms.

More than half the study population got intubation (64%). Cross-overs from monitored anesthesia to intubation were counted in the monitored anesthesia arm at a conversion rate of 13%.

Nogueira's group recalled that general anesthesia was associated with a decreased treatment effect, larger infarct growth, and numerically less recanalization in the MR CLEAN trial.

Limitations cited by the researchers included lack of data on procedural variables and the possibility that early-treated patients were underrepresented in the cohort.

"This study represents, to our knowledge, the first systematic matched case-control analysis and the largest report addressing this critical issue," they wrote. This becomes particularly important in face of the decline in the use of general anesthesia for stroke thrombectomy."

"Given this trend and in face of our data, the routine use of general anesthesia for posterior circulation thrombectomy should be reconsidered and warrants further investigation."

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