This anesthesia-related analysis of a multicentre, prospective study assessed the association between anesthesia selection and outcomes from the EVT for AIS. The primary outcome of independence (mRS 0-2) at 3 months, as well as the mortality and morbidity rates, did not differ between the patients who received GA and those who received CS; however, the hemodynamic parameters and the fluid input were significantly different between the patients receiving the 2 types of anesthesia.
Previous observational studies have found better 90-day independent outcomes in patients who received CS6; however, the imbalance in age,19 ischemic severity,7,8,10,11,20 and ischemic site21 led to concern with regard to the selection bias and a cautious interpretation of the conclusion. Moreover, the association was also confounded by the intraprocedural parameters, such as the decrease in MAP >40%,22 the minimal diastolic blood pressure and the maximal SBP variability.21 Therefore, the preprocedure ischemia (site and severity) and the intraprocedure hemodynamic fluctuation were often regarded as confounding factors between anesthesia selection and independence after EVT. The sensitivity analysis from the recent metaanalysis23 indicated that the pooled incidence of independence (mRS score 0 to 2) from the RCTs favored GA; however, patients receiving GA had significantly higher morbidity and mortality rates compared with patients who received CS. Therefore, the evidence for selection of anesthesia for AIS patients undergoing EVT still requires results from a diverse population. Our results were from a nonrandomized study. However, the baseline NIHSS, the ischemic site, and the other preprocedure parameters were all comparable between the patients receiving the 2 types of anesthesia, and the primary outcome was also in accordance with the AnStroke trial,15 which studied the same subjects with anterior circulation ischemia. However, the other 2 recently completed trials, both SIESTA14 and GOLIATH,16 favored GA from the point of better 90-day independent outcome (mRS score 0 to 2).
The time from onset-to-recanalization is critical for the independent outcome in AIS patients after EVT, which may be affected by the etiological cause of ischemia. Good clinical outcomes at 90 days (mRS 0-2) was greatest with time from symptom onset to arterial puncture of under 2 hours and became nonsignificant after 7.3 hours,24 and was also closely related with the time to reperfusion.25 The TOAST classification of large artery atherosclerosis was found in 69 patients (46.3%) in our trial, and the onset-to-puncture time in our study was ~238 and 254 minutes in patients who received GA and CS, respectively, both of which were in the suggested effective time window. In addition, the onset-to-recanalization time in our trial (304 min in CS vs. 311 min in GA) was slightly longer than that in the AnStroke trial (250 min in CS vs. 254 min in GA),15 comparable with that reported in the MR CLEAN trial (349 min in CS vs. 334 min in GA)12 and shorter than those in some previous observational studies.9,26 In the current trial, the recanalization time would not influence the association between anesthesia selection and outcomes in AIS patients undergoing EVT.
The proportion of GA administered to patients undergoing EVT was higher in some observational studies10,20 than that in our study; however, in some recent trials,12,19,27 this proportion was lower than those found in the above-mentioned observational studies. It often takes more time to prepare GA induction and tracheal intubation than to prepare CS for patients, and needs more cooperation from anesthesiologists. Therefore, CS was the first choice of the interventional neurologists for EVT. In the EAST trial, the mean difference between GA and CS in door-to-puncture time (11 min) and onset-to-recanalization time (7 min) were acceptable. This small time difference might be explained by the fact that a special team of anesthesiologists was on duty at the intervention-treatment room to conduct all GA, but the agents for CS were administered by the anesthesiologists in only 23 cases (23.5%) in 2 centers (13.3%) and by the interventionists for the other cases. This time difference was not the confounding factor between anesthesia selection and independence for the patients who received EVT.
In the EAST trial, dexmedetomidine was the most frequently used agent (45.7%) during sedation; however, all administrations were performed by interventionists. In addition, no patients received analgesic or colloid during CS. Hence, a series of problems for AIS patients under sedation could occur, including substantial movement, respiratory depression and high conversion rate from sedation to GA. Even in the SIESTA14 trial, in which the anesthesia selection was randomized, a high rate of substantial movement, diverse drug choices and a high rate of conversion from CS to GA were detected. However, the number of movement and respiratory parameters were not recorded in the EAST trial. In addition, the proportions of induction with sufentanil and etomidate and maintenance with total intravenous anesthesia increased in this study compared with the study conducted by Jagani et al,21 in which fentanyl and propofol were primarily used. SBP and MAP were significantly decreased within 30 minutes after induction; however, the number of patients who received vasoactive drugs, particularly a vasoconstrictor, did not differ between the patients under the 2 anesthesia types, and a >40% decrease in MAP from the preprocedure value was not found in patients receiving GA.
This study has several limitations. First, the data were from a nonrandomized trial, and the anesthesia choice was decided by the interventional neurologists. However, the baseline characteristics of ischemia and demographics were well balanced. Second, the sample size was not calculated but predefined in the EAST trial and might be not sufficient to test the difference in 90-day mRS between the different anesthesia types. However, we calculated the power for testing the primary outcome divided by the anesthesia type as >85%. Third, some anesthesia-specific information was not collected in detail, including the ventilator parameters, end-expiratory carbon dioxide and real-time hemodynamic parameters, which might be potential risk factors for the independent outcome. However, the EAST study was an exploratory trial and had provided a foundation for further research in such populations, such as the ongoing CANVAS trial,5 a multicentre, parallel-group RCT observing the effect of anesthesia selection on independent outcome in patients with acute anterior circulation stroke undergoing EVT.
Among patients with AIS in the anterior circulation undergoing EVT, CS compared with GA did not result in more improvements in the independent status at 3 months after the procedure. RCTs are still needed to provide more perioperative evidence of the hemodynamics and respiration effects of anesthesia choice on outcomes of patients with AIS during EVT.
We gratefully acknowledge the enrolled centers and investigators for their outstanding work. The following centers and investigators were involved: Ya Peng, MD, Department of Neurosurgery, Changzhou No. 1 People’s Hospital, Changzhou, China; Yibin Cao, MD, Department of Neurology, Tangshan Gongren Hospital, Tangshan, China; Shengli Chen, MD, Department of Neurology, Chongqing Sanxia Central Hospital, Chongqing, China; Meng Zhang, MD, Department of Neurology, Daping Hospital, Chongqing, China; Changchun Jiang, MD, Department of Neurology, Baotou Central Hospital, Baotou, China; Xiaoxiang Peng, MD, Department of Neurology, Hubei Zhongshan Hospital, Wuhan, China; Cunfeng Song, MD, Department of Neurology, Liaocheng 3rd People’s Hospital, Liaocheng, China; Liping Wei, MD, Department of Neurology, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang, China; Qiyi Zhu, MD, Department of Neurology, People’s Hospital of Linyi City, China; Zaiyu Guo, MD, Department of Neurology, Tianjin Teda Hospital, Tianjin, China; Li Liu, MD, Department of Neurology, Chifeng Municipal Hospital, Chifeng, China; Hang Lin, MD, Department of Neurology, Fuzhou PLA General Hospital, Fuzhou, China; Hua Yang, MD, Department of Neurology, Affiliated Hospital of Guiyang Medical College, Guiyang, China; Wei Wu, MD, Department of Neurology, QiLu Hospital of ShanDong University, Jinan, China; Hui Liang, MD, Department of Neurology, Yantai Hill Hospital, Yantai, China; Anding Xu, MD, Department of Neurology, The First Affiliated Hospital of Jinan University, China; and Kangning Chen, MD, Department of Neurology, Xinan Hospital, China.
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved
acute ischemic stroke; anesthesia; large artery occlusion; outcome