General Anesthesia Compared With Non-GA in Endovascular Thrombectomy for Ischemic Stroke

Background

and objectives Endovascular thrombectomy (EVT) for large vessel occlusion ischaemic stroke is either performed under general anesthesia (GA) or with non-GA techniques such as conscious sedation (CS) or local anesthesia (LA) alone. Previous small meta-analyses have demonstrated superior recanalization rates and improved functional recovery with GA compared with non-GA techniques. The publication of further RCTs could provide updated guidance when choosing between GA and non-GA techniques. Methods A systematic search for trials in which stroke EVT patients were randomised to GA or non-GA was performed in Medline, Embase and the Cochrane Central Register of Controlled Trials. A systematic review and meta-analysis using a random effects model was performed. Results Seven RCTs were included in the systematic review and meta-analysis. These trials included a total of 980 participants (GA, N=487; non-GA, N=493). GA improves recanalization by 9.0% (GA 84.6 % versus non-GA 75.6%; OR=1.75, 95% CI 1.26 to 2.42, P=0.0009) and the proportion of patients with functional recovery improves by 8.4% (GA 44.6 % versus non-GA 36.2%; OR=1.43, 95% CI 1.04 to 1.98, P=0.03). There was no difference in hemorrhagic complications or 3 month mortality. Conclusions In ischemic stroke patients treated with EVT, general anesthesia (GA) is associated with higher recanalization rates and improved functional recovery at 3 months compared with non-GA techniques. Conversion to GA and subsequent intention to treat analysis will underestimate the true therapeutic benefit. GA is established as effective in improving recanalization rates in EVT (7 Class 1 studies) with a high GRADE certainty rating. GA is established as effective in improving functional recovery at 3 months in EVT (5 Class 1 studies) with a moderate GRADE certainty rating. Stroke services need to develop pathways to incorporate GA as the first choice for most endovascular thrombectomy procedures in acute ischemic stroke with a level A recommendation for recanalization and level B recommendation for functional recovery.