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Title: 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
Authors: Campbell, Bruce C.V.
van Zwam, Wim H.
Goyal, Mayank
Menon, Bijoy K.
Dippel, Diederik W.J.
Demchuk, Andrew M.
Bracard, Serge
White, Philip
Dávalos, Antoni
Majoie, Charles B.L.M.
van der Lugt, Aad
Ford, Gary A.
de la Ossa, Natalia Pérez
Kelly, Michael
Bourcier, Romain
Donnan, Geoffrey A.
Roos, Yvo B.W.E.M.
Bang, Oh Young
Nogueira, Raul G.
Devlin, Thomas G.
van den Berg, Lucie A.
Clarençon, Frédéric
Burns, Paul
Carpenter, Jeffrey
Berkhemer, Olvert A.
Yavagal, Dileep R.
Pereira, Vitor Mendes
Ducrocq, Xavier
Dixit, Anand
Quesada, Helena
Epstein, Jonathan
Davis, Stephen M.
Jansen, Olav
Rubiera, Marta
Urra, Xabier
Micard, Emilien
Lingsma, Hester F.
Naggara, Olivier
Brown, Scott
Guillemin, Francis
Muir, Keith W.
van Oostenbrugge, Robert J.
Saver, Jeffrey L.
Jovin, Tudor G.
Hill, Michael D.
Mitchell, Peter J.
Fransen, Puck SS
Beumer, Debbie
Yoo, Albert J.
Schonewille, Wouter J.
Vos, Jan Albert
Nederkoorn, Paul J.
Wermer, Marieke JH
van Walderveen, Marianne AA
Staals, Julie
Hofmeijer, Jeannette
van Oostayen, Jacques A.
Lycklama à Nijeholt, Geert J.
Boiten, Jelis
Brouwer, Patrick A.
Emmer, Bart J.
de Bruijn, Sebastiaan F.
van Dijk, Lukas C.
Kappelle, Jaap
Lo, Rob H.
van Dijk, Ewoud J.
de Vries, Joost
de Kort, Paul L.M.
van Rooij, Willem Jan J.
van den Berg, Jan S.P.
van Hasselt, Boudewijn A.A.M.
Aerden, Leo A.M.
Dallinga, René J.
Visser, Marieke C.
Bot, Joseph C.J.
Vroomen, Patrick C.
Eshghi, Omid
Schreuder, Tobien H.C.M.L.
Heijboer, Roel J.J.
Keizer, Koos
Tielbeek, Alexander V.
den Hertog, Heleen M.
Gerrits, Dick G.
van den Berg-Vos, Renske M.
Karas, Giorgos B.
Steyerberg, Ewout W.
Flach, Zwenneke
Marquering, Henk A.
Sprengers, Marieke E.S.
Jenniskens, Sjoerd F.M.
Beenen, Ludo F.M.
van den Berg, René
Koudstaal, Peter J.
UNESCO Clasification: 32 Ciencias médicas
320507 Neurología
Keywords: Brain Ischemia
Issue Date: 2018
Journal: The Lancet Neurology 
Abstract: Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09-2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75-3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14-2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding: Medtronic.
ISSN: 1474-4422
DOI: 10.1016/S1474-4422(17)30407-6
Source: The Lancet Neurology[ISSN 1474-4422],v. 17(1), p. 47-53 (Enero 2018)
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