Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of Interventional Management of Stroke (IMS) III Trial

Affiliations

¹ From Baptist Neuroscience Associates, Baptist Health, Louisville, KY (A.A.-C.); Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.); Department of Neurology, Royal Melbourne Hospital, Parkville, Australia (B.Y.); Departments of Neurosurgery, Radiology, and Public Health Sciences, Penn State Hershey, PA (K.C.); Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, Calgary, AB, Canada (M.G.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology (P.K., J.S., J.B.) and Department of Radiology (T.T.), University of Cincinnati, OH; Departments of Radiology and Neurological Surgery, Columbia University, New York, NY (P.M.); Department of Neurology, University of Mississippi, Jackson (R.S.); Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle, Germany (K.E.W.); and Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (M.D.H.). achebl@yahoo.com.
² From Baptist Neuroscience Associates, Baptist Health, Louisville, KY (A.A.-C.); Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.); Department of Neurology, Royal Melbourne Hospital, Parkville, Australia (B.Y.); Departments of Neurosurgery, Radiology, and Public Health Sciences, Penn State Hershey, PA (K.C.); Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, Calgary, AB, Canada (M.G.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology (P.K., J.S., J.B.) and Department of Radiology (T.T.), University of Cincinnati, OH; Departments of Radiology and Neurological Surgery, Columbia University, New York, NY (P.M.); Department of Neurology, University of Mississippi, Jackson (R.S.); Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle, Germany (K.E.W.); and Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (M.D.H.).

PMID: 26138125
PMCID: PMC4519363
DOI: 10.1161/STROKEAHA.115.008761

Clinical Trial

Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of Interventional Management of Stroke (IMS) III Trial

Alex Abou-Chebl et al. Stroke. 2015 Aug.

. 2015 Aug;46(8):2142-8.

doi: 10.1161/STROKEAHA.115.008761. Epub 2015 Jul 2.

Affiliations

¹ From Baptist Neuroscience Associates, Baptist Health, Louisville, KY (A.A.-C.); Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.); Department of Neurology, Royal Melbourne Hospital, Parkville, Australia (B.Y.); Departments of Neurosurgery, Radiology, and Public Health Sciences, Penn State Hershey, PA (K.C.); Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, Calgary, AB, Canada (M.G.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology (P.K., J.S., J.B.) and Department of Radiology (T.T.), University of Cincinnati, OH; Departments of Radiology and Neurological Surgery, Columbia University, New York, NY (P.M.); Department of Neurology, University of Mississippi, Jackson (R.S.); Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle, Germany (K.E.W.); and Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (M.D.H.). achebl@yahoo.com.
² From Baptist Neuroscience Associates, Baptist Health, Louisville, KY (A.A.-C.); Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.); Department of Neurology, Royal Melbourne Hospital, Parkville, Australia (B.Y.); Departments of Neurosurgery, Radiology, and Public Health Sciences, Penn State Hershey, PA (K.C.); Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, Calgary, AB, Canada (M.G.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology (P.K., J.S., J.B.) and Department of Radiology (T.T.), University of Cincinnati, OH; Departments of Radiology and Neurological Surgery, Columbia University, New York, NY (P.M.); Department of Neurology, University of Mississippi, Jackson (R.S.); Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle, Germany (K.E.W.); and Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (M.D.H.).

PMID: 26138125
PMCID: PMC4519363
DOI: 10.1161/STROKEAHA.115.008761

Abstract

Background and purpose: General anesthesia (GA) for endovascular therapy (EVT) of acute ischemic stroke may be associated with worse outcomes.

Methods: The Interventional Management of Stroke III trial randomized patients within 3 hours of acute ischemic stroke onset to intravenous tissue-type plasminogen activator±EVT. GA use within 7 hours of stroke onset was recorded per protocol. Good outcome was defined as 90-day modified Rankin Scale ≤2. A multivariable analysis adjusting for dichotomized National Institutes of Health Stroke Scale (NIHSS; 8-19 versus ≥20), age, and time from onset to groin puncture was performed.

Results: Four hundred thirty-four patients were randomized to EVT, 269 (62%) were treated under local anesthesia and 147 (33.9%) under GA; 18 (4%) were undetermined. The 2 groups were comparable except for median baseline NIHSS (16 local anesthesia versus 18 GA; P<0.0001). The GA group was less likely to achieve a good outcome (adjusted relative risk, 0.68; confidence interval, 0.52-0.90; P=0.0056) and had increased in-hospital mortality (adjusted relative risk, 2.84; confidence interval, 1.65-4.91; P=0.0002). Those with medically indicated GA had worse outcomes (adjusted relative risk, 0.49; confidence interval, 0.30-0.81; P=0.005) and increased mortality (relative risk, 3.93; confidence interval, 2.18-7.10; P<0.0001) with a trend for higher mortality with routine GA. There was no significant difference in the adjusted risks of subarachnoid hemorrhage (P=0.32) or symptomatic intracerebral hemorrhage (P=0.37).

Conclusions: GA was associated with worse neurological outcomes and increased mortality in the EVT arm; this was primarily true among patients with medical indications for GA. Relative risk estimates, though not statistically significant, suggest reduced risk for subarachnoid hemorrhage and symptomatic intracerebral hemorrhage under local anesthesia. Although the reasons for these associations are not clear, these data support the use of local anesthesia when possible during EVT.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424.

Keywords: anesthesia; embolectomy; endovascular procedures; injections, intra-arterial; stroke; thrombolysis.

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Figures

**Figure**
Distribution of modified Rankin Scale scores of disability at 3 months.

See this image and copyright information in PMC

Comment in

Use of General Anesthesia for Emergent Large Vessel Occlusion Patients.
Burnsed BC, Arthur AS. Burnsed BC, et al. World Neurosurg. 2015 Dec;84(6):1498-500. doi: 10.1016/j.wneu.2015.10.028. Epub 2015 Oct 22. World Neurosurg. 2015. PMID: 26481338 No abstract available.

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Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of Interventional Management of Stroke (IMS) III Trial

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Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of Interventional Management of Stroke (IMS) III Trial

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