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- Title
Association of General Anesthesia vs Procedural Sedation With Functional Outcome Among Patients With Acute Ischemic Stroke Undergoing Thrombectomy: A Systematic Review and Meta-analysis.
- Authors
Schönenberger, Silvia; Hendén, Pia Löwhagen; Simonsen, Claus Z.; Uhlmann, Lorenz; Klose, Christina; Pfaff, Johannes A. R.; Yoo, Albert J.; Sørensen, Leif H.; Ringleb, Peter A.; Wick, Wolfgang; Kieser, Meinhard; Möhlenbruch, Markus A.; Rasmussen, Mads; Rentzos, Alexandros; Bösel, Julian
- Abstract
<bold>Importance: </bold>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.<bold>Objective: </bold>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.<bold>Data Source: </bold>MEDLINE search for English-language articles published from January 1, 1980, to July 31, 2019.<bold>Study Selection: </bold>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.<bold>Data Extraction and Synthesis: </bold>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.<bold>Main Outcomes and Measures: </bold>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.<bold>Results: </bold>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.<bold>Conclusions and Relevance: </bold>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.
- Subjects
CEREBRAL ischemia; CLINICAL trials; COMPARATIVE studies; DISABILITY evaluation; RESEARCH methodology; MEDICAL cooperation; META-analysis; PEOPLE with disabilities; RESEARCH; STROKE; VEIN surgery; CONSCIOUS sedation; EVALUATION research; TREATMENT effectiveness; GENERAL anesthesia; NIH Stroke Scale; THROMBECTOMY
- Publication
JAMA: Journal of the American Medical Association, 2019, Vol 322, Issue 13, p1283
- ISSN
0098-7484
- Publication type
journal article
- DOI
10.1001/jama.2019.11455