Comparing General Anesthesia-Based Regimens for Endovascular Treatment of Acute Ischemic Stroke: A Systematic Review and Network Meta-Analysis

Abstract

Background: Total intravenous anesthesia (TIVA)-based and volatile-based general anesthesia have different effects on cerebral hemodynamics. The current work compares these 2 regimens in acute ischemic stroke patients undergoing endovascular therapy.

Methods: We conducted a systematic literature search across MEDLINE, Embase, Cochrane, CINAHL, Web of Science, and Scopus. We identified English language studies including adult acute ischemic stroke patients managed with endovascular therapy under general anesthesia delineable into TIVA only and/or volatile only, and obtained categorical data for favorable functional outcomes using the modified Rankin scale (mRS ≤2), at 90 days after endovascular therapy. Odds ratios (OR) and standardized mean differences were calculated to inform a network meta-analysis approach, which permitted the inclusion of studies comparing a form of general anesthesia (ie, TIVA only or volatile only) to conscious sedation.

Results: The search rendered 6235 articles, of which 15 met inclusion criteria. Three studies directly investigated TIVA versus volatile, whereas 12 studies compared general anesthesia to conscious sedation. The total number of subjects was 3015 (conscious sedation: n = 1067; general anesthesia: n = 1948 [TIVA: n = 1212, volatile: n = 736]). No significant differences were identified between TIVA and volatile groups in 90-day neurological outcome (OR = 1.25, 95% confidence interval [CI], 0.81-1.91; P = .31), 90-day mortality (OR = 0.72, 95% CI, 0.42-1.24; P = .24), successful recanalization (OR = 1.33, 95% CI, 0.70-2.52; P = .39), or recanalization time (standardized mean difference = 0.03, 95% CI, -0.35 to 0.41; P = .88). Additionally, no significant differences were identified between the conscious sedation group and the TIVA group in 90-day neurological outcome (OR = 1.14, 95% CI, 0.84-1.53; P = .40), 90-day mortality (OR = 0.87, 95% CI, 0.62-1.23; P = .43), successful recanalization (OR = 0.76, 95% CI, 0.52-1.10; P = .15), or recanalization time (standardized mean difference = -0.18, 95% CI, -0.47 to 0.11; P = .23), and between the conscious sedation group and the volatile group in 90-day neurological outcome (OR = 1.42, 95% CI, 0.92-2.17; P = .11), 90-day mortality (OR = 0.63, 95% CI, 0.36-1.12; P = .11), successful recanalization (OR = 1.01, 95% CI, 0.52-1.94; P = .98), or recanalization time (standardized mean difference = -0.15, 95% CI, -0.52 to 0.23; P = .44).

Conclusions: This network meta-analysis showed that the perioperative use of either general anesthesia-based regimen, or sedation, did not significantly impact various endovascular therapy-related outcomes. However, the current work was underpowered to detect differences in anesthetic agents, clinico-demographic characteristics, or procedural factors.