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Observational Study
. 2025 May;56(5):1191-1199.
doi: 10.1161/STROKEAHA.124.049358. Epub 2025 Mar 25.

General Anesthesia Versus Conscious Sedation in Thrombectomy Patients With Low NIHSS Anterior Circulation Stroke

Christian Heitkamp  1 , Fabian Flottmann  1 , Tobias D Faizy  1   2 , Alexander Heitkamp  1 , Christian Thaler  1 , Vincent Geest  1 , Maximilian Schell  3 , Helge C Kniep  1 , Gabriel Broocks  1   4 , Matthias Bechstein  1 , Lukas Meyer  1 , Uta Hanning  1 , Götz Thomalla  3 , Jens Fiehler  1 , Laurens Winkelmeier  1 ; GSR-ET Investigators
Collaborators, Affiliations
Observational Study

General Anesthesia Versus Conscious Sedation in Thrombectomy Patients With Low NIHSS Anterior Circulation Stroke

Christian Heitkamp et al. Stroke. 2025 May.

Abstract

Background: The optimal anesthetic approach for patients with acute ischemic stroke with large vessel occlusion but low National Institutes of Health Stroke Scale receiving mechanical thrombectomy remains unclear. We aimed to evaluate the association of anesthetic strategies with procedural and clinical outcomes, hypothesizing that conscious sedation/local anesthesia (CS/LA) may offer a more favorable risk-benefit ratio than general anesthesia (GA).

Methods: Multicenter cohort study screening all thrombectomy patients prospectively enrolled in GSR-ET (German Stroke Registry-Endovascular Treatment) across 25 centers between 2015 and 2021. Patients with an admission National Institutes of Health Stroke Scale score of <6 and large vessel occlusion in the anterior circulation underwent 1:1 propensity score matching by their anesthetic strategy during mechanical thrombectomy (CS/LA versus GA). Outcome measures were an excellent functional outcome (modified Rankin Scale score of 0-1 at 90 days) and successful recanalization (modified Thrombolysis in Cerebral Infarction score of 2b-3).

Results: Of 13 082 thrombectomy cases, 814 had a National Institutes of Health Stroke Scale <6, of whom 36% received CS/LA and 64% received GA. Before matching, CS/LA patients were less often male (46% versus 54%; P=0.043), had lower National Institutes of Health Stroke Scale scores at admission (median, 3 versus 4; P=0.002), and the M1 segment of the middle cerebral artery was more often occluded (51% versus 39%; P<0.001). After matching, 582 patients were included, and baseline and imaging characteristics were balanced between CS/LA and GA. CS/LA and GA patients achieved similar rates of successful recanalization (85% versus 89%; P=0.14). However, complete recanalization (modified Thrombolysis in Cerebral Infarction score of 3) was less often observed in CS/LA patients (45% versus 61%; P<0.001; adjusted odds ratio, 0.44 [95% CI, 0.30-0.65]; P<0.001). CS/LA patients achieved more often excellent functional outcomes (59% versus 48%; P=0.005; adjusted odds ratio, 1.99 [95% CI, 1.34-2.95]; P=0.001).

Conclusions: In thrombectomy patients with minor stroke, the rate of successful recanalization was comparable between CS/LA and GA. However, our results suggest a more favorable risk-benefit ratio of CS/LA, with an increased rate of excellent functional outcomes.

Keywords: angiography; cohort studies; registries; stroke; thrombectomy.

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Conflict of interest statement

Dr Flottmann reported receiving personal fees from Eppdata GmbH outside the submitted work. Dr Kniep reported an ownership stake in Eppdata GmbH and compensation from Eppdata GmbH for consultant services outside the submitted work. Dr Faizy reported grants from the German Research Foundation/Deutsche Forschungsgesellschaft (DFG; project number: 411621970) and personal fees from Eppdata GmbH outside the submitted work. Dr Broocks reported grants from the American Society of Neuroradiology and receiving compensation as a speaker from Balt and personal fees from Eppdata GmbH outside the submitted work. Dr Meyer reported receiving compensation as a speaker from Balt and personal fees from Eppdata GmbH outside the submitted work. Dr Thaler reported receiving personal fees from Eppdata GmbH outside the submitted work. Dr Thomalla reported grants from FP7 Health and grants from AstraZeneca. In addition, he reported receiving personal fees from Acandis, Alexion, Amarin, Bayer, Boehringer Ingelheim, Bristol Myers Squibb/Pfizer, Daiichi Sankyo, Portola, and Stryker outside the submitted work. Dr Fiehler reported stock holdings in Tegus Medical; compensation from Tonbridge for consultant services; stock holdings in Vastrax; compensation from Roche for consultant services; compensation from TG Medical for consultant services; and compensation from Penumbra Inc for consultant services. In addition, he reported an ownership stake in Eppdata GmbH and grants and personal fees from Acandis, Cerenovus, MicroVention, Medtronic, Stryker, and Phenox and grants from Route 92 outside the submitted work. The other authors report no conflicts.

Figures

Figure.
Figure.
Final recanalization results and functional outcomes stratified by the anesthestic strategy. Procedural and functional outcomes of patients with minor stroke undergoing mechanical thrombectomy. Distribution of the final recanalization result (A) and functional outcome 90 days after treatment (B) stratified by anesthetic strategy during endovascular procedure. Please note that there was no significant difference in successful recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3) between patients who underwent general anesthesia (GA) and those with conscious sedation/local anesthesia (CS/LA; straight line in A, 89% vs 85%; P=0.14). However, patients with CS/LA had more often excellent functional outcomes 90 days after treatment (straight line in B, 59% vs 48%; P=0.005). mRS indicates modified Rankin Scale.
See this image and copyright information in PMC

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