Observational Study

. 2021 Jan 12;96(2):e171-e181.

doi: 10.1212/WNL.0000000000011006. Epub 2020 Oct 7.

Blood Pressure During Endovascular Treatment Under Conscious Sedation or Local Anesthesia

Noor Samuels¹, Rob A van de Graaf², Carlijn A L van den Berg², Daan Nieboer², Ismail Eralp², Kilian M Treurniet², Bart J Emmer², Rogier V Immink², Charles B L M Majoie², Wim H van Zwam², Reinoud P H Bokkers², Maarten Uyttenboogaart², Boudewijn A A M van Hasselt², Jörg Mühling², James F Burke², Bob Roozenbeek², Aad van der Lugt², Diederik W J Dippel², Hester F Lingsma², Adriaan C G M van Es²; MR CLEAN Registry Investigators

Collaborators, Affiliations

Collaborators

MR CLEAN Registry Investigators:
Diederik W J Dippel, Aad van der Lugt, Charles B L M Majoie, Yvo B W E M Roos, Robert J van Oostenbrugge, Wim H van Zwam, Jelis Boiten, Jan Albert Vos, Ivo G H Jansen, Maxim J H L Mulder, Robert-Jan B Goldhoorn, Wouter J Schonewille, Jonathan M Coutinho, Marieke J H Wermer, Marianne A A van Walderveen, Julie Staals, Jeannette Hofmeijer, Jasper M Martens, Geert J Lycklama à Nijeholt, Bob Roozenbeek, Bart J Emmer, Sebastiaan F de Bruijn, Lukas C van Dijk, H Bart van der Worp, Rob H Lo, Ewoud J van Dijk, Hieronymus D Boogaarts, Paul L M de Kort, Jo J P Peluso, Jan S P van den Berg, Boudewijn A A M van Hasselt, Leo A.M. Aerden, René J Dallinga, Maarten Uyttenboogaart, Omid Eshghi, Tobien H C M L Schreuder, Roel J J Heijboer, Koos Keizer, Lonneke S F Yo, Heleen M den Hertog, Emiel J C Sturm, Marieke E S Sprengers, Sjoerd F M Jenniskens, René van den Berg, Albert J Yoo, Ludo F M Beenen, Alida A Postma, Stefan D Roosendaal, Bas F W van der Kallen, Ido R. van den Wijngaard, Adriaan C G M van Es, Joost Bot, Pieter-Jan van Doormaal, H Zwenneke Flach, Hester F Lingsma, Naziha el Ghannouti, Martin Sterrenberg, Corina Puppels, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, Cathelijn van Rijswijk, Gert Messchendorp, Hester Bongenaar, Karin Bodde, Sandra Kleijn, Jasmijn Lodico, Hanneke Droste, M Wollaert, D Jeurrissen, Ernas Bos, Yvonne Drabbe, Marjan Elfrink, Berber Zweedijk, Mostafa Khalilzada, Esmee Venema, Vicky Chalos, Kars C J Compagne, Ralph R Geuskens, Tim van Straaten, Saliha Ergezen, Roger R M Harmsma, Daan Muijres, Anouk de Jong, Wouter Hinsenveld, Olvert A. Berkhemer, Anna M.M. Boers, J Huguet, P F C Groot, Marieke A. Mens, Katinka R. van Kranendonk, Kilian M. Treurniet, Manon Kappelhof, Manon L Tolhuijsen, Heitor Alves

Affiliations

¹ From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor. n.samuels@erasmusmc.nl.
² From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor.

PMID: 33028664
PMCID: PMC7905780
DOI: 10.1212/WNL.0000000000011006

Observational Study

Blood Pressure During Endovascular Treatment Under Conscious Sedation or Local Anesthesia

Noor Samuels et al. Neurology. 2021.

. 2021 Jan 12;96(2):e171-e181.

doi: 10.1212/WNL.0000000000011006. Epub 2020 Oct 7.

Authors

Collaborators

MR CLEAN Registry Investigators:
Diederik W J Dippel, Aad van der Lugt, Charles B L M Majoie, Yvo B W E M Roos, Robert J van Oostenbrugge, Wim H van Zwam, Jelis Boiten, Jan Albert Vos, Ivo G H Jansen, Maxim J H L Mulder, Robert-Jan B Goldhoorn, Wouter J Schonewille, Jonathan M Coutinho, Marieke J H Wermer, Marianne A A van Walderveen, Julie Staals, Jeannette Hofmeijer, Jasper M Martens, Geert J Lycklama à Nijeholt, Bob Roozenbeek, Bart J Emmer, Sebastiaan F de Bruijn, Lukas C van Dijk, H Bart van der Worp, Rob H Lo, Ewoud J van Dijk, Hieronymus D Boogaarts, Paul L M de Kort, Jo J P Peluso, Jan S P van den Berg, Boudewijn A A M van Hasselt, Leo A.M. Aerden, René J Dallinga, Maarten Uyttenboogaart, Omid Eshghi, Tobien H C M L Schreuder, Roel J J Heijboer, Koos Keizer, Lonneke S F Yo, Heleen M den Hertog, Emiel J C Sturm, Marieke E S Sprengers, Sjoerd F M Jenniskens, René van den Berg, Albert J Yoo, Ludo F M Beenen, Alida A Postma, Stefan D Roosendaal, Bas F W van der Kallen, Ido R. van den Wijngaard, Adriaan C G M van Es, Joost Bot, Pieter-Jan van Doormaal, H Zwenneke Flach, Hester F Lingsma, Naziha el Ghannouti, Martin Sterrenberg, Corina Puppels, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, Cathelijn van Rijswijk, Gert Messchendorp, Hester Bongenaar, Karin Bodde, Sandra Kleijn, Jasmijn Lodico, Hanneke Droste, M Wollaert, D Jeurrissen, Ernas Bos, Yvonne Drabbe, Marjan Elfrink, Berber Zweedijk, Mostafa Khalilzada, Esmee Venema, Vicky Chalos, Kars C J Compagne, Ralph R Geuskens, Tim van Straaten, Saliha Ergezen, Roger R M Harmsma, Daan Muijres, Anouk de Jong, Wouter Hinsenveld, Olvert A. Berkhemer, Anna M.M. Boers, J Huguet, P F C Groot, Marieke A. Mens, Katinka R. van Kranendonk, Kilian M. Treurniet, Manon Kappelhof, Manon L Tolhuijsen, Heitor Alves

Affiliations

¹ From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor. n.samuels@erasmusmc.nl.
² From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor.

PMID: 33028664
PMCID: PMC7905780
DOI: 10.1212/WNL.0000000000011006

Abstract

Objective: To evaluate the role of blood pressure (BP) as mediator of the effect of conscious sedation (CS) compared to local anesthesia (LA) on functional outcome after endovascular treatment (EVT).

Methods: Patients treated in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry centers with CS or LA as preferred anesthetic approach during EVT for ischemic stroke were analyzed. First, we evaluated the effect of CS on area under the threshold (AUT), relative difference between baseline and lowest procedural mean arterial pressure (∆LMAP), and procedural BP trend, compared to LA. Second, we assessed the association between BP and functional outcome (modified Rankin Scale [mRS]) with multivariable regression. Lastly, we evaluated whether BP explained the effect of CS on mRS.

Results: In 440 patients with available BP data, patients treated under CS (n = 262) had larger AUTs (median 228 vs 23 mm Hg*min), larger ∆LMAP (median 16% vs 6%), and a more negative BP trend (-0.22 vs -0.08 mm Hg/min) compared to LA (n = 178). Larger ∆LMAP and AUTs were associated with worse mRS (adjusted common odds ratio [acOR] per 10% drop 0.87, 95% confidence interval [CI] 0.78-0.97, and acOR per 300 mm Hg*min 0.89, 95% CI 0.82-0.97). Patients treated under CS had worse mRS compared to LA (acOR 0.59, 95% CI 0.40-0.87) and this association remained when adjusting for ∆LMAP and AUT (acOR 0.62, 95% CI 0.42-0.92).

Conclusions: Large BP drops are associated with worse functional outcome. However, BP drops do not explain the worse outcomes in the CS group.

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Figures

**Figure 1. Schematic Illustration of Procedural Blood Pressure Measures**
1. Mean arterial pressure (MAP) value on admission. 2. Lowest MAP. 3. Area under the threshold. 4. Relative difference between baseline MAP and lowest MAP (∆LMAP). 5. Average trend (slope). ED = emergency department; EVT = endovascular treatment.

**Figure 2. Flowchart of Patient Selection**
CS = conscious sedation; EVT = endovascular treatment; GA = general anesthesia; LA = local anesthesia; MR CLEAN = Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands.

**Figure 3. Procedural Blood Pressure (BP) for Patients Treated Under Conscious Sedation or Local Anesthesia**
(A) Nonsmoothed mean systolic BP curves for both anesthetic modalities with 95% tolerance interval (band). (B) Smoothed mean systolic BP curves during EVT procedure for both anesthetic modalities (continuous line) with 95% tolerance interval (dotted line).

**Figure 4. Primary Outcome on the Modified Rankin Scale (mRS) by Preferred Anesthetic Method**

See this image and copyright information in PMC

References

1. Berkhemer OA, van den Berg LA, Fransen PS, et al. . The effect of anesthetic management during intra-arterial therapy for acute stroke in MR CLEAN. Neurology 2016;87:656–664. - PubMed
1. Campbell BCV, van Zwam WH, Goyal M, et al. . 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. Lancet Neurol 2018;17:47–53. - PubMed
1. van de Graaf RA, Samuels N, Mulder M, et al. . Conscious sedation or local anesthesia during endovascular treatment for acute ischemic stroke. Neurology 2018;91:e19–e25. - PMC - PubMed
1. Goldhoorn RB, Bernsen MLE, Hofmeijer J, et al. . Anesthetic management during endovascular treatment of acute ischemic stroke in the MR CLEAN registry. Neurology 2020;94:e97-e106. - PubMed
1. Davis MJ, Menon BK, Baghirzada LB, et al. . Anesthetic management and outcome in patients during endovascular therapy for acute stroke. Anesthesiology 2012;116:396–405. - PubMed

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Blood Pressure During Endovascular Treatment Under Conscious Sedation or Local Anesthesia

Collaborators

Affiliations

Blood Pressure During Endovascular Treatment Under Conscious Sedation or Local Anesthesia

Authors

Collaborators

Affiliations

Abstract

Figures

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical