General Anesthesia Versus Conscious Sedation for Mechanical Thrombectomy in Acute Anterior Circulation Ischemic Stroke

Abstract

Background Retrospective studies suggested that general anesthesia (GA) for mechanical thrombectomy has worse outcomes compared with conscious sedation (CS). However, randomized single‐center trials suggested noninferiority of GA to CS. We investigated the impact of anesthesia techniques on thrombectomy, and hypothesized that the routine use of GA with a defined protocol would not adversely affect thrombectomy delivery or outcomes. Methods A total of 451 consecutive patients receiving mechanical thrombectomy for anterior circulation ischemic stroke from 2016 to 2019 were identified from the local registry. Patients were divided into cohort A when both GA and CS were used, and cohort B (from October 2017) when GA became the default method. Favorable functional outcome was defined as modified Rankin scale of 0 to 2 at 3 months. Intraprocedural blood pressures were audited annually. Results In cohort A, compared with patients receiving CS, patients with GA had prolonged median arrival to arterial puncture time (26 versus 18 minutes; P<0.001) and comparable favorable functional outcome at 3 months (37.7% versus 45.1%; P=0.355). In cohort B, the median arrival to arterial puncture was reduced to 10 minutes, with comparable favorable functional outcome of 46.7%, and reduced mortality compared with cohort A (14.2% versus 22.7%; P=0.024). Yearly audits demonstrated good adherence to the protocol. Binary logistic regression analysis showed only old age (odds ratio [OR], 1.04; 95% CI, 1.02–1.07 [P=0.003]), high National Institute of Health Stroke Scale at presentation (OR, 1.17; 95% CI, 1.08–1.26 [P<0.001]), and poor collateral status (OR, 0.29; 95% CI, 0.12–0.72 [P=0.008]) were independent factors predicting for poor prognosis, not GA (OR, 0.71; 95% CI, 0.32–1.60 [P=0.408]). Conclusions Patients treated under GA for mechanical thrombectomy achieved comparable functional outcome at 3 months compared with those under CS. Through practice and a defined protocol, GA for mechanical thrombectomy can achieve sustainable good functional outcomes. Large clinical trials are needed to confirm these findings.