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Meta-Analysis
. 2023 Apr 18;100(16):e1655-e1663.
doi: 10.1212/WNL.0000000000207066. Epub 2023 Feb 16.

General Anesthesia Compared With Non-GA in Endovascular Thrombectomy for Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Douglas Campbell  1 , Elise Butler  2 , Ruby Blythe Campbell  1 , Jess Ho  2 , P Alan Barber  2
Affiliations
Meta-Analysis

General Anesthesia Compared With Non-GA in Endovascular Thrombectomy for Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Douglas Campbell et al. Neurology. .

Abstract

Background and objectives: Endovascular thrombectomy (EVT) for large vessel occlusion ischemic stroke is either performed under general anesthesia (GA) or with non-GA techniques such as conscious sedation or local anesthesia alone. Previous small meta-analyses have demonstrated superior recanalization rates and improved functional recovery with GA when compared with non-GA techniques. The publication of further randomized controlled trials (RCTs) could provide updated guidance when choosing between GA and non-GA techniques.

Methods: A systematic search for trials in which stroke EVT patients were randomized to GA or non-GA was performed in Medline, Embase, and the Cochrane Central Register of Controlled Trials. A systematic review and meta-analysis using a random-effects model was performed.

Results: Seven RCTs were included in the systematic review and meta-analysis. These trials included a total of 980 participants (GA, N = 487; non-GA, N = 493). GA improves recanalization by 9.0% (GA 84.6% vs non-GA 75.6%; odds ratio [OR] 1.75, 95% CI 1.26-2.42, p = 0.0009), and the proportion of patients with functional recovery improves by 8.4% (GA 44.6% vs non-GA 36.2%; OR 1.43, 95% CI 1.04-1.98, p = 0.03). There was no difference in hemorrhagic complications or 3-month mortality.

Discussion: In patients with ischemic stroke treated with EVT, GA is associated with higher recanalization rates and improved functional recovery at 3 months compared with non-GA techniques. Conversion to GA and subsequent intention-to-treat analysis will underestimate the true therapeutic benefit. GA is established as effective in improving recanalization rates in EVT (7 Class 1 studies) with a high Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) certainty rating. GA is established as effective in improving functional recovery at 3 months in EVT (5 Class 1 studies) with a moderate GRADE certainty rating. Stroke services need to develop pathways to incorporate GA as the first choice for most EVT procedures in acute ischemic stroke with a level A recommendation for recanalization and level B recommendation for functional recovery.

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Conflict of interest statement

The authors report no relevant disclosures. Go to Neurology.org/N for full disclosures.

Figures

Figure 1
Figure 1. Flow Diagram for Systematic Review
CS = conscious sedation; GA = general anesthesia; RCT = randomized controlled trial.
Figure 2
Figure 2. Forest Plots of Pooled Effect Estimate for (A) Recanalization Success, (B) Good Functional Recovery, (C) 3-Month Mortality, and (D) Hemorrhagic Complications
Pooled estimates were performed only if trials reported the endpoint and in the correct format. GA = general anesthesia.
See this image and copyright information in PMC

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