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General anesthesia or conscious sedation for thrombectomy in stroke patients: an updated systematic review and meta-analysis

Anesthésie générale ou sédation consciente pour la thrombectomie chez les personnes victimes d’un accident vasculaire cérébral : une mise à jour sous forme de revue systématique avec méta-analyse

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Abstract

Purpose

Endovascular treatment for stroke patients usually requires anesthesia care, with no current consensus on the best anesthetic management strategy. Several randomized controlled trials and meta-analyses have attempted to address this. In 2022, additional evidence from three new trials was published: the GASS trial, the CANVAS II trial, and preliminary results from the AMETIS trial, prompting the execution of this updated systematic review and meta-analysis. The primary objective of this study was to evaluate the effects of general anesthesia and conscious sedation on functional outcomes measured with the modified Rankin scale (mRS) at three months.

Methods

We performed a systematic review and meta-analysis of randomized controlled trials investigating conscious sedation and general anesthesia in endovascular treatment. The following databases were examined: PubMed, Scopus, Embase, and the Cochrane Database of Randomized Controlled Trials and Systematic Reviews. The Risk of Bias 2 tool was used to assess bias. In addition, trial sequence analysis was performed on the primary outcome to estimate if the cumulative effect is significant enough to be unaffected by further studies.

Results

Nine randomized controlled trials were identified, including 1,342 patients undergoing endovascular treatment for stroke. No significant differences were detected between general anesthesia and conscious sedation with regards to mRS, functional independence (mRS, 0–2), procedure duration, onset to reperfusion, mortality, hospital length of stay, and intensive care unit length of stay. Patients treated under general anesthesia may have more frequent successful reperfusion, though the time from groin to reperfusion was slightly longer. Trial sequential analysis showed that additional trials are unlikely to show marked differences in mean mRS at three months.

Conclusions

In this updated systematic review and meta-analysis, the choice of anesthetic strategy for endovascular treatment of stroke patients did not significantly impact functional outcome as measured with the mRS at three months. Patients managed with general anesthesia may have more frequent successful reperfusion.

Trial registration

PROSPERO (CRD42022319368); registered 19 April 2022.

Résumé

Objectif

Le traitement endovasculaire pour les patient·es victimes d’un accident vasculaire cérébral (AVC) nécessite généralement des soins d’anesthésie, mais il n’existe actuellement aucun consensus sur la meilleure stratégie de prise en charge anesthésique. Plusieurs études randomisées contrôlées et méta-analyses ont tenté d’aborder cette question. En 2022, des données probantes supplémentaires provenant de trois nouvelles études ont été publiées : l’étude GASS, l’étude CANVAS II et les résultats préliminaires de l’étude AMETIS, ce qui a motivé la réalisation de cette revue systématique et méta-analyse mises à jour. L’objectif principal de cette étude était d’évaluer les effets de l’anesthésie générale et de la sédation consciente sur les devenirs fonctionnels mesurés avec l’échelle de Rankin modifiée (mRS) à trois mois.

Méthode

Nous avons réalisé une revue systématique avec méta-analyse d’études randomisées contrôlées portant sur la sédation consciente et l’anesthésie générale dans le traitement endovasculaire. Les bases de données suivantes ont été examinées : PubMed, Scopus, Embase et la base de données Cochrane des études randomisées contrôlées et des revues systématiques. L’outil Risque de biais 2 a été utilisé pour évaluer le biais. De plus, une analyse séquentielle des études a été effectuée sur le critère d’évaluation principal afin d’estimer si l’effet cumulatif était suffisamment significatif pour ne pas être affecté par d’autres études.

Résultats

Neuf études randomisées contrôlées ont été identifiées, incluant 1342 patient·es bénéficiant d’un traitement endovasculaire pour un AVC. Aucune différence significative n’a été détectée entre l’anesthésie générale et la sédation consciente en ce qui concerne la mRS, l’indépendance fonctionnelle (mRS, 0-2), la durée de l’intervention, le moment d’apparition de la reperfusion, la mortalité, la durée de séjour à l’hôpital et la durée de séjour en unité de soins intensifs. Les patient·es traité·es sous anesthésie générale pourraient avoir une reperfusion réussie plus fréquente, bien que le temps entre l’aine et la reperfusion était légèrement plus long. L’analyse séquentielle des études a montré qu’il est peu probable que d’autres études montrent des différences marquées dans la mRS moyenne à trois mois.

Conclusion

Dans cette revue systématique et méta-analyse mises à jour, le choix de la stratégie anesthésique pour le traitement endovasculaire des personnes victimes d’un AVC n’a pas eu d’impact significatif sur les devenirs fonctionnels mesurés avec la mRS à trois mois. La réussite de la reperfusion pourrait être plus fréquente chez les patient·es pris·es en charge par anesthésie générale.

Enregistrement de l’étude

PROSPERO (CRD42022319368); enregistrée le 19 avril 2022.

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Author contributions

Federico Geraldini conceived the idea, performed the initial search, contacted corresponding authors for missing data, performed the statistical analysis, and wrote and edited the manuscript. Paolo Diana conceived the idea, manually reviewed and assessed each of the included studies, and wrote and edited the manuscript. Davide Fregolent reviewed titles, abstracts, and full text manuscripts for potential inclusion and wrote and edited the manuscript. Alessandro De Cassai helped with the statistical evaluation, performed the ROB2 evaluation, and wrote and edited the manuscript. Annalisa Boscolo performed the ROB 2 evaluation and wrote and edited the manuscript. Tommaso Pettenuzzo performed the GRADE assessment, manually reviewed and assessed each of the included studies, and wrote and edited the manuscript. Nicolò Sella screened for duplicates, supervised the ROB 2 evaluation, resolving disputes, and helped with the revision and editing of the manuscript. Irene Lupelli reviewed titles, abstracts, and full text manuscripts for potential inclusion and critically revised and edited the manuscript. Paolo Navalesi supervised the project, helped with the interpretation and contextualization of the results, and critically assessed and edited the finalized manuscript. Marina Munari helped plan the research, assessed it for overall merit, supervised the project, helped with the interpretation and contextualization of the results, and critically assessed and edited the finalized manuscript.

Disclosures

All authors have no conflict of interest to report.

Funding statement

No funding to declare.

Editorial responsibility

This submission was handled by Dr. Stephan K. W. Schwarz, Editor-in-Chief, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

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Authors and Affiliations

  1. UOC Anesthesia and Intensive Care Unit, Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy

    Federico Geraldini MD, Paolo Diana MD, Alessandro De Cassai MD, Annalisa Boscolo PhD, Tommaso Pettenuzzo MD, Nicolò Sella MD, Paolo Navalesi MD & Marina Munari MD

  2. Department of Medicine, University of Padua, Padua, Italy

    Davide Fregolent MD, Irene Lupelli MD & Paolo Navalesi MD

  3. Neurointensive Care Unit, Padua University Hospital, Padua, Italy

    Marina Munari MD

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Geraldini, F., Diana, P., Fregolent, D. et al. General anesthesia or conscious sedation for thrombectomy in stroke patients: an updated systematic review and meta-analysis. Can J Anesth/J Can Anesth 70, 1167–1181 (2023). https://doi.org/10.1007/s12630-023-02481-8

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