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J Stroke > Volume 23(1); 2021 > Article
Feil, Herzberg, Dorn, Tiedt, Küpper, Thunstedt, Hinske, Mühlbauer, Goss, Liebig, Dieterich, Bayer, Kellert, and on Behalf of the GSR Investigators: General Anesthesia versus Conscious Sedation in Mechanical Thrombectomy

Abstract

Background and Purpose

Anesthesia regimen in patients undergoing mechanical thrombectomy (MT) is still an unresolved issue.

Methods

We compared the effect of anesthesia regimen using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) between June 2015 and December 2019. Degree of disability was rated by the modified Rankin Scale (mRS), and good outcome was defined as mRS 0-2. Successful reperfusion was assumed when the modified thrombolysis in cerebral infarction scale was 2b-3.

Results

Out of 6,635 patients, 67.1% (n=4,453) patients underwent general anesthesia (GA), 24.9% (n=1,650) conscious sedation (CS), and 3.3% (n=219) conversion from CS to GA. Rate of successful reperfusion was similar across all three groups (83.0% vs. 84.2% vs. 82.6%, P=0.149). Compared to the CA-group, the GA-group had a delay from admission to groin (71.0 minutes vs. 61.0 minutes, P<0.001), but a comparable interval from groin to flow restoration (41.0 minutes vs. 39.0 minutes). The CS-group had the lowest rate of periprocedural complications (15.0% vs. 21.0% vs. 28.3%, P<0.001). The CS-group was more likely to have a good outcome at follow-up (42.1% vs. 34.2% vs. 33.5%, P<0.001) and a lower mortality rate (23.4% vs. 34.2% vs. 26.0%, P<0.001). In multivariable analysis, GA was associated with reduced achievement of good functional outcome (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.71 to 0.94; P=0.004) and increased mortality (OR, 1.42; 95% CI, 1.23 to 1.64; P<0.001). Subgroup analysis for anterior circulation strokes (n=5,808) showed comparable results.

Conclusions

We provide further evidence that CS during MT has advantages over GA in terms of complications, time intervals, and functional outcome.

Introduction

While mechanical thrombectomy (MT) is the standard of care in eligible patients with large vessel occlusion (LVO), the appropriate anesthesia regimen is still an unresolved issue. The primary goal of sedation management during MT is to enable the interventionalist to perform the procedure as quickly and safely as possible. However, studies on this topic have shown conflicting results. A recent meta-analysis from three randomized single-center trials showed an advantage for general anesthesia (GA) compared to conscious sedation (CS) in patients with anterior circulation strokes who underwent MT with respect to 3-month outcome [1]. Contrary to this, a post hoc analysis from 797 patients from the Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) Collaboration showed that patients treated without GA had a better 3-month outcome compared to those treated under GA [2]. Data from another registry on anesthesia regimens with 4,429 patients showed [3], that GA was associated with worse functional outcome, especially when compared with local anesthesia. Due to the lack of evidence from large clinical trials on this topic, these results have to be interpreted with caution. The supposed advantages of GA would be the patients’ immobilization during MT, proper pain management, airway protection and therefore fewer periprocedural complications. The more optimal periprocedural conditions are said to lead to higher rates of successful reperfusion resulting in better functional outcome [1]. On the other hand, GA may cause a delay before groin puncture and result in complications related to intensive care management leading to an overall delay in the hospital stay. Advantages of CS include clinical and neurological monitoring, fewer hemodynamic fluctuations, and potentially shorter procedures. However, unprotected airways and patient movement are believed to have a negative influence on functional outcome. Here we aimed to analyze the real-life practice of anesthesia regimen in MT-patients from the German Stroke Registry-Endovascular Treatment (GSR-ET) and its impact on complications and outcome [4].

Methods

Data from the GSR-ET (https://www.clinicaltrials.gov; NCT03356392) were analyzed. Details of the registry have been published previously [4,5]. See Appendix 1 for steering committee members of GSR (GSR investigators).

Study population

Between June 2015 and December 2019, 6,635 patients from 25 sites in Germany with acute ischemic stroke due to LVO, who were treated with MT, were included. The decision for MT was based on the interdisciplinary decision of treating physicians including clinical and imaging parameters and according to national (German Neurological Society) and international guidelines (European Stroke Organization, American Heart Association) [6-8].
Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS). Pre- and post-stroke disability was rated by the modified Rankin Scale (mRS). Early infarct signs were assessed by the Alberta Stroke Program Early CT Score (ASPECTS). Site of occlusion was determined by computed tomography angiography, magnetic resonance angiography, or angiography. Reperfusion success was measured by the modified thrombolysis in cerebral infarction (mTICI) scale and mTICI 2b-3 was rated as successful reperfusion.
The periprocedural anesthesia regimen was based on individual and interdisciplinary decisions and in-house protocols. In general, patients received either GA or CS; a small group converted from CS to GA for various periprocedural reasons. In 313 patients, the anesthesia regimen was not documented.

Statistical analysis

Continuous variables were tested for normal distribution using the Kolmogorov-Smirnov test. Normally distributed data were presented as mean±standard deviation and non-normally distributed data as median (interquartile range) or counts and percentages. Clinical characteristics, imaging data, periprocedural times, and outcome parameters were compared across the three groups using the Kruskal-Wallis test or median-test, as appropriate. Binary logistic regression analysis was performed for good outcome (mRS 0-2) and mortality at follow-up, including variables that were either statistically or clinically (or biologically) significant. For logistic regression analysis, categorical variables were defined as follows: sex male=0, female=1; intravenous thrombolysis treatment no=0, yes=1; successful recanalization no=0, yes=1; type of anesthesia CS=0, GA=1; intracerebral hemorrhage (ICH) no=0, yes=1; tandem lesion no=0, yes=1; posterior circulation stroke no=0, yes =1; pretreatment with oral anticoagulants no=0, yes=1. Converted patients and patients with unknown anesthesia regimen were excluded from the logistic analysis. For all statistical testing, we used the SPSS version 25.0 for Windows (IBM Co., Armonk, NY, USA).

Ethics

The study was conducted in accordance with the Declaration of Helsinki and was centrally approved by the Institutional Review Board (IRB) of the Ludwig-Maximilians-Universität Munich (protocol No. 689-15). Further approval was obtained from local IRBs according to local regulations. Informed consent was not mandatory in accordance with the IRB approval since there were no study-specific procedures performed and data analysis of all patients undergoing MT was demanded by the governmental quality surveillance system.

Results

Out of 6,635 patients from the GSR-ET, 67.1% (n=4,453) underwent GA and 24.9% (n=1,650) CS during MT. In 3.3% of all patients (n=219), the anesthesia regimen was converted from initial CS to GA, while the anesthesia regimen was not documented in 313 patients (4.7%). The CS- and GA-groups were of similar age and sex, but patients from the GA-group had higher pre-stroke modified Rankin Scale (pmRS) and higher NIHSS on admission (Table 1). CS-patients were more often admitted via drip and ship (48.5% vs. 41.2% vs. 49.3%, P<0.001). Further, the CS-group had more often patients with right-sided (48.7% vs. 40.9% vs. 41.1%, P=0.002) and anterior circulation stroke (95.3% vs. 85.0% vs. 88.6%, P<0.001). The rate of successful reperfusion was similar in all three groups (83.0% vs. 84.2% vs. 82.6%, P=0.149). While tandem lesions were more frequent in the GA-group (13.4% vs. 16.4% vs. 17.8%, P=0.011), rate of acute treatment of ipsilateral internal carotid artery (stenting and/or percutaneous transluminal angioplasty) was comparable in all groups (10.2% vs. 11.8% vs. 11.4%, P=0.110). GA compared to CS was associated with a significant delay from admission to groin (61.0 minutes vs. 71.0 minutes vs. 61.0 minutes, P<0.001). Time from groin to flow restoration did not differ between the GA- and the CS-groups (39.0 minutes vs. 41.0 minutes), while the converted group had a significantly longer time interval from groin to flow restoration (64.5 minutes, P<0.001). Overall, the CS-group showed the lowest rate of periprocedural complications (15.0% vs. 21.0% vs. 28.3%, P<0.001).
GA was independently associated with higher periprocedural complications (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.35 to 1.86; P<0.001) (Table 2). In the GA-group, patients were more likely to receive intensive antithrombotic medications (Table 1). In the CS-group, rates of periprocedural ICH (1.7% vs. 2.8% vs. 5.9%, P<0.001) and complications during the whole hospital stay (42.7% vs. 46.6% vs. 53.5%, P=0.002) were lowest. Hospital stay was significantly shorter in the CS-group compared to GA-group and the converted group (9.5±7.5 days vs. 11.3±9.5 days vs. 11.1±8.1 days, P<0.001).
At 24 hours, CS patients performed better with respect to NIHSS (8 vs. 11 vs. 13, P<0.001). Three-month follow up was not available in 15.4% (n=1,021). The patients in the CS-group were more likely to achieve good outcome (42.1% vs. 34.2% vs. 33.5%, P<0.001) and had a lower rate of mortality (23.4% vs. 32.4% vs. 26.0%, P<0.001) (Figure 1A).
In multivariable analysis, GA was associated with reduced achievement of good functional outcome (OR, 0.82; 95% CI, 0.71 to 0.94; P=0.004) and increased mortality (OR, 1.42; 95% CI, 1.23 to 1.64; P<0.001) (Tables 3 and 4).
We performed an additional analysis, restricted to patients with anterior circulation strokes (n=5,808) (Supplementary Table 1), which showed comparable results with respect to time delay, complications, and outcome parameters (Figure 1B and Supplementary Tables 2 and 3).

Discussion

Here we present by far the largest sample size on anesthesia regimens in 6,635 MT-patients with the following results: GA was the most common strategy in centers within the GSR-ET; more than two-thirds of the patients received MT under GA. The GA-rate is considerably higher than reported in data from clinical trials or registry data with about 30% of patients receiving GA (28.0% to 37.6%) [9-12]. In about 12% of patients starting MT under CS, a conversion to GA was necessary (corresponding to 3% of the whole cohort). This is in line with rates that ranged from about 10% to 15% in other studies [13-17]. In our study, patients from the CS-group performed better with respect to clinical outcomes at 24 hours, at discharge, and at follow-up after 3 months than patients with MT under GA.
Time intervals showed delayed start of groin puncture in GA-patients and therefore longer time intervals from admission to flow restoration. Successful reperfusion rate was similar across all three patient groups. More periprocedural and in-hospital complications were observed under GA—independently of possible confounders, such as tandem lesions, posterior circulation stroke, or number of passages. The interpretation of this result remains speculative. Possibly, there are confounders we cannot address appropriately yet, such as changes in blood pressure caused by GA or imbalances in baseline parameters. Thus the regression analysis cannot appropriately adjust for all these confounders. Well-balanced groups in clinical trials would be necessary to overcome these shortcomings.
Overall, these findings are in contrast to prior studies, but in line with data from another registry analyzing 4,429 patients [3]. A recent meta-analysis from three clinical trials showed an advantage of GA with respect to outcome, an effect that was most probably driven by higher rates of successful reperfusion in the GA-group [1]. Investigators speculated that GA leads to more optimal interventional conditions, resulting in higher reperfusion rates [1]. A post hoc analysis from 797 patients from the HERMES collaboration showed non-GA patients to have a higher rate of good outcome at 3 months compared to GA-patients [2]. However, in this post hoc analysis only 30% of patients were treated under GA. Besides, they used data from RCTs, which were much more homogenous with respect to pmRS, baseline parameters, and occlusion side than in our study [2]. Poorer outcome in the GA-group was most probably not only caused by periprocedural complications but could partly be explained by the fact that the GA- and CS-groups were not fully balanced. With respect to periprocedural complications, we observed higher rates of dissection and perforation, ICH, and vasospasm in the GA-group and the converted group. These complications could have been clinical reason for conversion from CS to GA.
A recent analysis from a prospective Italian registry (Italian Registry of Endovascular Treatment of Acute Stroke [IRETAS]) showed that two-thirds of these patients were treated with CS or local anesthesia. In contrast, in centers from the GSR-ET two thirds of patients underwent MT under GA. Our patients had a pmRS of 0-1 in about 80% compared to up to 90% in IRETAS. ASPECTS in the GSR was 8-9 and 10 in IRETAS. This might partially explain the observation of different sedation regimens. However, due to different sedation regimens and different study populations the comparability of both studies is limited. Besides, our data provide further evidence for anesthesia and sedation management, especially regarding periprocedural complications that have been less well explored using a large dataset.
Our data show significantly lower systolic and diastolic blood pressure and heart rate at admission in the GA-group. However, we have no data on the temporal changes of blood pressure data, especially a significant drop which potentially increases infarct size, leading to poor outcome [18]. In the GA-group, the cumulative dose of norepinephrine—reflecting the drop in blood pressure under GA—was an independent predictor of an unfavorable outcome [19]. On the other hand, vasospasm occurred most frequently under GA. As high PaO2 is discussed to cause intracerebral vasospasm, this effect might be more likely to occur under GA than under CS [20]. However, our data do not allow any conclusion on causality to be drawn. Thus, the causality between GA and higher occurrence of vasospasm as a periprocedural complication is speculative. In converted patients, we neither provided information on the time of the periprocedural complication nor of the conversion from GA to CS. Therefore, we cannot conclude that the periprocedural complication rate is lower in the GA-group.
With regard to the total complication rate during the hospital stay, there were clear differences with a disadvantage of GA, especially regarding the occurrence of ICH and all other complications. In the GA-group, antithrombotic medication was used more intensively. In terms of complications, rates of ICH were highest in patients treated under GA. In summary, patients under GA performed worse in every aspect.
We observed no influence of anesthesia regimen on successful reperfusion rates. The number of passages was highest in the converted group and lowest in the CS-group. However, in the GA-group, periprocedural time to groin puncture was extended by an average of 10 minutes and the delay was not compensated by the MT procedure time. Retrospective studies have suggested that the time delay through intubation may lead to worse outcome [21]. While patients undergoing MT under CS had slightly lower NIHSS at admission (13 vs. 15 in median), the difference in clinical stroke severity continued and even increased with respect to NIHSS and mRS after 24 hours, at discharge, and at 3-month follow-up. Regression analysis showed that CS was independently associated with higher probability of good outcome and lower odds for mortality at 3 months adjusted to confounders like baseline NIHSS. Patients who converted from CS to GA also had better outcome than patients in the GA- group. Besides poorer clinical outcome, GA was associated with a longer hospital stay of 2 days.
The strengths of our study include the large study cohort prospectively collected from a nationwide multicenter registry. Our data therefore represent clinical decisions on sedation management and anesthesia regimen in daily life practice, outside clinical trials. We observed the same results for the whole cohort of LVO patients as well as for anterior circulation strokes. We were able to analyze detailed information on complications and clinical follow-up. Given that it is unlikely that evidence will be established from large clinical trials in the near future, our results provide further evidence based on observational data that patients benefit from CS compared to GA.
However, our study has some limitations. Our data are observational, non-randomized and non-controlled. Therefore, interpretation of the data is prone to bias. Underlying selection bias for decision for an anesthesia regimen have to be discussed as well, even if individual variables in the patient baseline data did not differ. Individual clinical parameters, such as pmRS, NIHSS at admission or presence of tandem lesions, could have contributed to the decision for anesthesia regimens; however, we cannot analyze this in more detail retrospectively. Furthermore, we provide no information about the periprocedural use of sedative agents (type, dosage), further need of intensive care treatment, the duration of mechanical ventilation, and the reason for conversion from GA to CS. Apart from the vital signs at admission, there are no extensive data on the course of these vital signs and their impact on complications and outcome. Further, the CS-group also included patients who only received local anesthesia as a distinction between local anesthesia and CS was not made in the GSR-ET register.

Conclusions

Our study showed an influence on the functional and clinical outcome after MT by the choice of anesthesia regimen with advantages for CS compared to GA in terms of complications, functional outcome, and mortality.

Supplementary materials

Supplementary materials related to this article can be found online at https://doi.org/10.5853/jos.2020.02404.
Supplementary Table 1.
Characteristics of GSR patients with anterior circulation stroke comparing the anesthesia regimen (n=5,808 patients, unknown in n=256)
jos-2020-02404-suppl1.pdf
Supplementary Table 2.
Logistic regression for good outcome in anterior circulation stroke patients at follow-up
jos-2020-02404-suppl2.pdf
Supplementary Table 3.
Logistic regression for mortality in anterior circulation stroke patients at follow-up
jos-2020-02404-suppl2.pdf

Notes

Disclosure
Thomas Liebig consults for Stryker Neurovascular GmbH and has received speaker honoraria from Pfizer, Covidien, Phenox, and Microvention outside this study.
Lars Kellert has received funding for travel or speaker honoraria from Bayer Vital, Boehringer Ingelheim, Bristol-Meyer-Squibb, Daiichi Sankyo, and Pfizer outside of this study.

Acknowledgments

The authors thank Katie Göttlinger and J Stuart Lund for proofreading the manuscript.

Figure 1.
Modified Rankin Scale (mRS) at 3-months follow-up for all large vessel occlusion stroke (A) and for anterior circulation stroke (B). Good outcome mRS ≤2.
jos-2020-02404f1.jpg
Table 1.
Characteristics of GSR-patients comparing the anesthesia regimen (n=6,635 patients, unknown in n=313)
Characteristic Conscious sedation (n=1,650, 24.9%) General anesthesia (n=4,453, 67.1%) Conversion (n=219, 3.3%) P
Age (yr) 73.4±13.0 73.1±13.1 70.3±13.3 0.340
Female sex 835 (50.6) 2,265 (50.9) 98 (44.7) 0.206
Clinical characteristics at admission
 pmRS 0 (0-1) (missing in n=45) 0 (0-1) (missing in n=342) 0 (0-1) (missing in n=15) 0.004
  pmRS ≤ 1 1,278 (77.5) 3,237 (72.7) 167 (76.3) 0.017
 Baseline NIHSS 13 (8-11) 15 (10-19) 15 (9-18) <0.001
 Drip and ship 800 (48.5) 1,834 (41.2) 108 (49.3) <0.001
 BP systolic at admission 154.7±27.4 151.0±27.4 155.5±28.0 <0.001
 BP diastolic at admission 84.4±17.0 82.0±17.0 86.0±16.0 <0.001
 Heart rate at admission 82.4±19.1 81.5±19.2 84.5±18.5 0.015
 OAC at admission 332 (20.1) 896 (20.1) 35 (16.0) 0.116
Risk factors
 Arterial hypertension 1,229 (74.5) 3,265 (73.3) 157 (71.7) <0.001
 Diabetes mellitus 342 (20.7) 934 (21.0) 46 (21.0) 0.119
 Hypercholesterolemia 532 (32.2) 1,753 (39.4) 77 (35.2) <0.001
 Current smoking 208 (12.6) 585 (13.1) 40 (18.3) <0.001
 Atrial fibrillation 662 (40.1) 1,765 (39.6) 82 (37.4) 0.348
Imaging data
 ASPECTS 9 (7-10) 9 (7-10) 8 (7-10) 0.010
 Tandem lesion 221 (13.4) 730 (16.4) 39 (17.8) 0.011
 Anterior circulation 1,572 (95.3) 3,786 (85.0) 194 (88.6) <0.001
 Right-sided occlusion 810 (48.7) 1,824 (40.9) 90 (41.1) 0.002
Type of occlusion*
 Basilar artery 50 (3.0) 556 (12.5) 17 (7.8) <0.001
 Vertebral artery 6 (0.4) 121 (2.7) 3 (1.4) <0.001
 PCA 30 (1.8) 147 (3.3) 8 (3.7) 0.003
 ACA 35 (2.1) 108 (2.4) 3 (1.4) 0.521
 Carotid-T 250 (15.2) 766 (17.2) 39 (17.8) 0.184
 ICA intracranial 85 (5.2) 227 (5.1) 17 (7.8) 0.213
 ICA extracranial 132 (8.0) 295 (6.6) 16 (7.3) 0.144
 MCA, proximal M1 529 (32.1) 1,346 (30.2) 72 (32.9) 0.219
 MCA, distal M1 394 (23.9) 778 (17.5) 40 (18.3) <0.001
 MCA, M2 361 (21.9) 959 (21.5) 45 (20.5) 0.422
Time intervals (min)
 Admission to groin 61.0 (40.0-89.0) 71.0 (47.0-103.0) 61.0 (41.0-83.0) <0.001
 Groin to flow restoration 39.0 (25.0-63.0) 41.0 (26.0-65.0) 64.5 (42.0-100.0) <0.001
 Admission to flow restoration 107.0 (76.0-143.0) 118.5 (88.0-160.0) 129.0 (97.8-179.0) <0.001
Treatment
 IVT treatment 846 (51.3) 2,208 (49.6) 129 (58.9) 0.018
 Additive medication during thrombectomy 327 (19.8) 1,548 (34.8) 54 (24.7) <0.001
  ASA 18 (1.1) 92 (2.1) 5 (2.3) 0.036
  Clopidogrel 2 (0.1) 14 (0.3) 1 (0.5) 0.373
  Ticagrelor 0 (0) 21 (0.5) 1 (0.5) 0.020
  Tirofiban 21 (1.3) 136 (3.1) 9 (4.1) <0.001
  Abciximab 0 (0) 3 (0.1) 1 (0.5) 0.040
  Heparin 226 (13.7) 1,067 (24.0) 33 (1.4) <0.001
  rtPA 47 (2.8) 93 (2.1) 6 (2.7) 0.194
 Acute treatment ipsilateral ICA (stenting and/or PTA) 169 (10.2) 526 (11.8) 25 (11.4) 0.110
 No. of passages 2.0±1.6 2.2±1.8 2.5±1.9 <0.001
 Periprocedural complications 248 (15.0) 934 (21.0) 62 (28.3) <0.001
  Device malfunction 9 (0.5) 21 (0.5) 2 (0.9) 0.995
  Dissection, perforation 42 (2.5) 130 (2.9) 14 (6.4) 0.007
  Clot migration, embolization 55 (3.3) 185 (4.2) 9 (4.1) 0.426
  ICH 29 (1.7) 127 (2.8) 13 (5.9) <0.001
  Vasospasm 57 (3.5) 389 (8.7) 22 (10.0) <0.001
  Resuscitation 8 (0.5) 13 (0.3) 2 (0.9) 0.070
  Other 110 (6.7) 272 (6.1) 23 (10.5) 0.003
 Successful reperfusion mTICI 2b/3 1,370 (83.0) 3,751 (84.2) 181 (82.6) 0.149
24-hr follow-up
 mRS 4 (3-5) (missing in n=93) 5 (3-5) (missing in n=491) 5 (4-5) (missing in n=32) 0.170
 NIHSS 8 (3-16) 11 (4-20) 13 (5-23) <0.001
 Complications 705 (42.7) 2,076 (46.6) 117 (53.5) 0.002
  Malignant MCA infarction 69 (4.2) 284 (6.4) 15 (6.8) 0.001
  Recurrent stroke 62(3.8) 264 (5.9) 6 (2.7) <0.001
  ICH 187 (11.3) 625 (14.0) 47 (21.5) <0.001
  Myocardial infarction 30 (1.8) 75 (1.7) 2 (0.9) 0.612
  Groin hematoma 34 (2.1) 64 (1.4) 7 (3.2) 0.406
  Groin aneurysm 14 (0.8) 30 (0.7) 1 (0.5) 0.693
  Other complications 426 (25.8) 1,278 (28.7) 72 (32.9) 0.023
 Hospital stay (day) 9.5±7.5 11.3±9.5 11.1±8.1 <0.001
Discharge
 NIHSS 4 (1-11) 5 (2-12) 6 (2-13) 0.022
 mRS 3 (2-5) (missing in n=17) 4 (2-5) (missing in n=325) 4 (2-5) (missing in n=9) <0.001
 Mortality (mRS 6) 188 (11.4) 775 (17.4) 27 (12.3) <0.001
Values are presented as mean±standard deviation, number (%), or median (interquartile range).
GSR, German Stroke Registry; pmRS, pre-stroke modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; BP, blood pressure; OAC, oral anticoagulation; ASPECTS, Alberta Stroke Program Early CT Score; PCA, posterior cerebral artery; ACA, anterior cerebral artery; ICA, internal carotid artery; MCA, middle cerebral artery; IVT, intravenous thrombolysis; ASA, acetylsalicylic acid; rtPA, recombinant tissue plasminogen activator; PTA, percutaneous transluminal angioplasty; ICH, intracerebral hemorrhage; mTICI, modified thrombolysis in cerebral infarction; mRS, modified Rankin Scale.
* Multiple occlusion sites possible.
Table 2.
Logistic regression for periprocedural complications during mechanical thrombectomy in general anesthesia- and conscious sedation-groups
Variable OR 95% CI P
Age 0.99 0.98-0.99 0.002
Sex 1.09 0.93-1.27 0.291
pmRS 1.11 1.03-1.18 0.004
NIHSS at admission 0.99 0.98-1.01 0.533
Treatment with IVT 1.02 0.86-1.21 0.840
General anesthesia 1.58 1.35-1.86 <0.001
Tandem lesion 1.21 0.98-1.50 0.080
Posterior circulation stroke 0.57 0.13-2.59 0.470
Time from admission to groin puncture 1.00 0.99-1.00 0.153
ASPECTS 1.01 0.96-1.05 0.787
No. of passages 1.18 1.14-1.23 <0.001
Pretreatment (OAC) 0.78 0.62-0.97 0.025
OR, odds ratio; CI, confidence interval; pmRS, pre-stroke modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; IVT, intravenous thrombolysis; ASPECTS, Alberta Stroke Program Early CT Score; OAC, oral anticoagulation.
Table 3.
Logistic regression for good outcome in general anesthesia- and conscious sedation-groups at follow-up
Variable OR 95% CI P
Age 0.95 0.95-0.96 <0.001
Sex 1.01 0.87-1.17 0.885
pmRS 0.53 0.49-0.58 <0.001
NIHSS at admission 0.89 0.88-0.90 <0.001
Treatment with IVT 1.73 1.50-2.00 <0.001
Successful reperfusion (mTICI 2b/3) 4.87 3.82-6.22 <0.001
General anesthesia 0.82 0.71-0.94 0.004
ICH 0.26 0.21-0.33 <0.001
Time from admission to groin 0.99 0.999-1.00 0.019
OR, odds ratio; CI, confidence interval; pmRS, pre-stroke modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; IVT, intravenous thrombolysis; mTICI, modified thrombolysis in cerebral infarction; ICH, intracerebral hemorrhage.
Table 4.
Logistic regression for mortality in general anesthesia- and conscious sedation-groups at follow-up
Variable OR 95% CI P
Age 1.06 1.05-1.07 <0.001
Sex 0.90 0.78-1.05 0.167
pmRS 1.35 1.27-1.42 <0.001
NIHSS at admission 1.09 1.07-1.10 <0.001
Treatment with IVT 0.64 0.56-0.74 <0.001
Successful reperfusion (mTICI 2b/3) 0.28 0.24-0.34 <0.001
General anesthesia 1.42 1.23-1.64 <0.001
ICH 2.71 2.26-3.25 <0.001
Time from admission to groin 1.00 1.00-1.00 0.114
OR, odds ratio; CI, confidence interval; pmRS, pre-stroke modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; IVT, intravenous thrombolysis; mTICI, modified thrombolysis in cerebral infarction; ICH, intracerebral hemorrhage.

References

1. Schönenberger S, Hendén PL, Simonsen CZ, Uhlmann L, Klose C, Pfaff JAR, et al. Association of general anesthesia vs procedural sedation with functional outcome among patients with acute ischemic stroke undergoing thrombectomy: a systematic review and meta-analysis. JAMA 2019;322:1283-1293.
crossref pmid pmc
2. Campbell BCV, van Zwam WH, Goyal M, Menon BK, Dippel DWJ, Demchuk AM, et al. Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol 2018;17:47-53.
pmid
3. Cappellari M, Pracucci G, Forlivesi S, Saia V, Nappini S, Nencini P, et al. General anesthesia versus conscious sedation and local anesthesia during thrombectomy for acute ischemic stroke. Stroke 2020;51:2036-2044.
pmid
4. Wollenweber FA, Tiedt S, Alegiani A, Alber B, Bangard C, Berrouschot J, et al. Functional outcome following stroke thrombectomy in clinical practice. Stroke 2019;50:2500-2506.
pmid
5. Alegiani AC, Dorn F, Herzberg M, Wollenweber FA, Kellert L, Siebert E, et al. Systematic evaluation of stroke thrombectomy in clinical practice: the German stroke registry endovascular treatment. Int J Stroke 2019;14:372-380.
pmid
6. Ringleb PA, Hamann GF, Röther J, Jansen O, Groden C, Veltkamp R. Akuttherapie des ischämischen schlaganfalls: rekanalisierende therapie [Therapy of acute ischemic stroke: recanalisation therapy guideline]. Aktuelle Neurol 2016;43:82-91.

7. Turc G, Bhogal P, Fischer U, Khatri P, Lobotesis K, Mazighi M, et al. European Stroke Organisation (ESO)-European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg 2019;11:535-538.
crossref pmid
8. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018;49:e46-e110.
pmid
9. Bekelis K, Missios S, MacKenzie TA, Tjoumakaris S, Jabbour P. Anesthesia technique and outcomes of mechanical thrombectomy in patients with acute ischemic stroke. Stroke 2017;48:361-366.
crossref pmid pmc
10. Powers CJ, Dornbos D 3rd, Mlynash M, Gulati D, Torbey M, Nimjee SM, et al. Thrombectomy with conscious sedation compared with general anesthesia: a DEFUSE 3 analysis. AJNR Am J Neuroradiol 2019;40:1001-1005.
crossref pmid pmc
11. Shan W, Yang D, Wang H, Xu L, Zhang M, Liu W, et al. General anesthesia may have similar outcomes with conscious sedation in thrombectomy patients with acute ischemic stroke: a real-world registry in China. Eur Neurol 2018;80:7-13.
crossref pmid
12. Goldhoorn RB, Bernsen MLE, Hofmeijer J, Martens JM, Lingsma HF, Dippel DWJ, et al. Anesthetic management during endovascular treatment of acute ischemic stroke in the MR CLEAN Registry. Neurology 2020;94:e97-e106.
crossref pmid
13. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372:11-20.
pmid
14. Flottmann F, Leischner H, Broocks G, Faizy TD, Aigner A, Deb-Chatterji M, et al. Emergency conversion to general anesthesia is a tolerable risk in patients undergoing mechanical thrombectomy. AJNR Am J Neuroradiol 2020;41:122-127.
crossref pmid pmc
15. Ren C, Xu G, Liu Y, Liu G, Wang J, Gao J. Effect of conscious sedation vs. general anesthesia on outcomes in patients undergoing mechanical thrombectomy for acute ischemic stroke: a prospective randomized clinical trial. Front Neurol 2020;11:170.
crossref pmid pmc
16. Schönenberger S, Uhlmann L, Hacke W, Schieber S, Mundiyanapurath S, Purrucker JC, et al. Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy: a randomized clinical trial. JAMA 2016;316:1986-1996.
crossref pmid
17. Simonsen CZ, Sørensen LH, Juul N, Johnsen SP, Yoo AJ, Andersen G, et al. Anesthetic strategy during endovascular therapy: general anesthesia or conscious sedation? (GOLIATH - General or Local Anesthesia in Intra Arterial Therapy): a single-center randomized trial. Int J Stroke 2016;11:1045-1052.
crossref pmid
18. Petersen NH, Ortega-Gutierrez S, Wang A, Lopez GV, Strander S, Kodali S, et al. Decreases in blood pressure during thrombectomy are associated with larger infarct volumes and worse functional outcome. Stroke 2019;50:1797-1804.
crossref pmid pmc
19. Mundiyanapurath S, Stehr A, Wolf M, Kieser M, Möhlenbruch M, Bendszus M, et al. Pulmonary and circulatory parameter guided anesthesia in patients with ischemic stroke undergoing endovascular recanalization. J Neurointerv Surg 2016;8:335-341.
crossref pmid
20. Kety SS, Schmidt CF. The effects of altered arterial tensions of carbon dioxide and oxygen on cerebral blood flow and cerebral oxygen consumption of normal young men. J Clin Invest 1948;27:484-492.
crossref pmid pmc
21. Brinjikji W, Murad MH, Rabinstein AA, Cloft HJ, Lanzino G, Kallmes DF. Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis. AJNR Am J Neuroradiol 2015;36:525-529.
crossref pmid

Appendices

Appendix 1.

GSR investigators

Name Degree Organization Role Contribution
Tobias Boeckh-Behrens MD Klinikum r.d.Isar, Munich, Germany Site Investigator German Stroke Registry - Steering Committee
Silke Wunderlich MD Klinikum r.d.Isar, Munich, Germany Site Investigator German Stroke Registry - Steering Committee
Arno Reich MD Uniklinik RWTH Aachen, Germany Site Investigator German Stroke Registry - Steering Committee
Anastasios Mpotsaris MD Uniklinik RWTH Aachen, Germany Site Investigator German Stroke Registry - Steering Committee
Martin Wiesmann MD Uniklinik RWTH Aachen, Germany Site Investigator German Stroke Registry - Steering Committee
Ulrike Ernemann MD Tübingen University Hospital, Germany Site Investigator German Stroke Registry - Steering Committee
Till-Karsten Hauser MD Tübingen University Hospital, Germany Site Investigator German Stroke Registry - Steering Committee
Christian H Nolte MD Charite Campus Benjamin Franklin Site Investigator German Stroke Registry - Steering Committee
Eberhard Siebert MD Charité - Campus Benjamin Franklin und Campus Charité Mitte, Berlin, Germany Site Investigator German Stroke Registry - Steering Committee
Sarah Zweynert MD Charité - Campus Virchow Klinikum, Berlin, Germany Site Investigator German Stroke Registry - Steering Committee
Georg Bohner MD Charité - Campus Virchow Klinikum, Berlin, Germany Site Investigator German Stroke Registry - Steering Committee
Alexander Ludolph MD Sana Klinikum Offenbach, Germany Site Investigator German Stroke Registry - Steering Committee
Karl-Heinz Henn MD Sana Klinikum Offenbach, Germany Site Investigator German Stroke Registry - Steering Committee
Waltraud Pfeilschifter MD Uniklinik Frankfurt/ Main, Germany Site Investigator German Stroke Registry - Steering Committee
Marlis Wagner MD Uniklinik Frankfurt/ Main, Germany Site Investigator German Stroke Registry - Steering Committee
Joachim Röther MD Asklepios Klinik Altona, Hamburg, Germany Site Investigator German Stroke Registry - Steering Committee
Bernd Eckert MD Asklepios Klinik Altona, Hamburg, Germany Site Investigator German Stroke Registry - Steering Committee
Jörg Berrouschot MD Klinikum Altenburger Land, Altenburg, Germany Site Investigator German Stroke Registry - Steering Committee
Albrecht Bormann MD Klinikum Altenburger Land, Altenburg, Germany Site Investigator German Stroke Registry - Steering Committee
Anna Alegiani MD University Medical Center Hamburg-Eppendorf, Hamburg, Germany Site Investigator German Stroke Registry - Steering Committee
Jens Fiehler MD University Medical Center Hamburg-Eppendorf, Hamburg, Germany Site Investigator German Stroke Registry - Steering Committee
Fabian Flottmann MD University Medical Center Hamburg-Eppendorf, Hamburg, Germany Site Investigator German Stroke Registry - Steering Committee
Christian Gerloff MD University Medical Center Hamburg-Eppendorf, Hamburg, Germany Site Investigator German Stroke Registry - Steering Committee
Götz Thomalla MD University Medical Center Hamburg-Eppendorf, Hamburg, Germany Site Investigator German Stroke Registry - Steering Committee
Elke Hattingen MD University Hospital Bonn, Germany Site Investigator German Stroke Registry - Steering Committee
Gabor Petzold MD University Hospital Bonn, Germany Site Investigator German Stroke Registry - Steering Committee
Sven Thonke MD Klinikum Hanau, Germany Site Investigator German Stroke Registry - Steering Committee
Christopher Bangard MD Klinikum Hanau, Germany Site Investigator German Stroke Registry - Steering Committee
Christoffer Kraemer MD Klinikum Lüneburg, Germany Site Investigator German Stroke Registry - Steering Committee
Martin Dichgans MD Ludwig Maximilian University of Munich, Germany Site Investigator German Stroke Registry - Steering Committee
Marios Psychogios MD Georg-August-Universität Göttingen, Germany Site Investigator German Stroke Registry - Steering Committee
Jan Liman MD Georg-August-Universität Göttingen, Germany Site Investigator German Stroke Registry - Steering Committee
Martina Petersen MD Klinikum Osnabrück, Germany Site Investigator German Stroke Registry - Steering Committee
Florian Stögbauer MD Klinikum Osnabrück, Germany Site Investigator German Stroke Registry - Steering Committee
Peter Kraft MD University Hospital Würzburg, Germany Site Investigator German Stroke Registry - Steering Committee
Mirko Pham MD University Hospital Würzburg, Germany Site Investigator German Stroke Registry - Steering Committee
Michael Braun MD Bezirkskrankenhaus Günzburg, Germany Site Investigator German Stroke Registry - Steering Committee
Gerhard F. Hamann MD Bezirkskrankenhaus Günzburg, Germany Site Investigator German Stroke Registry - Steering Committee
Andreas Kastrup MD Klinikum Bremen Mitte, Germany Site Investigator German Stroke Registry - Steering Committee
Christian Roth MD Klinikum Bremen Mitte, Germany Site Investigator German Stroke Registry - Steering Committee
Klaus Gröschel MD University Medical Center Mainz, Germany Site Investigator German Stroke Registry - Steering Committee
Timo Uphaus MD University Medical Center Mainz, Germany Site Investigator German Stroke Registry - Steering Committee
Volker Limmroth MD Kliniken Köln, Germany Site Investigator German Stroke Registry - Steering Committee


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