https://www.medscape.com/viewarticle/892440?src=wnl_edit_tpal?src=soc_tw_share
LOS
ANGELES — The latest clinical trial of thrombectomy for acute ischemic
stroke has reinforced concerns about performing the endovascular
procedure under general anesthesia.
The DEFUSE 3 trial, reported at last month's International Stroke Conference (ISC) 2018 and simultaneously published in the New England Journal of Medicine, showed a large benefit of removing the clot by thrombectomy in patients presenting with a large-vessel occlusion 6 to 16 hours after stroke onset and still having salvageable brain tissue identified on perfusion imaging.
However, results of subgroup analysis suggest that this benefit is greatly curtailed in patients receiving the procedure under general anesthesia.
"I would recommend from these results that general anesthesia should be avoided if possible in patients having endovascular therapy for stroke," said Maarten Lansberg, MD, Stanford University Stroke Center, California, during his presentation here, also at ISC 2018.
"Quite a few trials have looked at the comparison of
thrombectomy performed under general anesthesia vs conscious sedation
and some of these have shown a worse outcome with general anesthesia, so
we wanted to look at this too," he explained.
"We tried to discourage general anesthesia in this trial because of prior data suggesting worse outcomes with this approach, but some sites prefer to use general anesthesia. So we still had 28% of our patients treated that way, and the other 72% received conscious sedation," Dr Lansberg noted.
When the patients treated with thrombectomy under conscious sedation were compared with the control group, there was a larger benefit and it was significant.
But when patients in the thrombectomy group who received the procedure under general anesthesia were compared with the control group, the benefit was much smaller and not significant, Dr Lansberg reported. However, he cautioned that the sample size was small, so it would be difficult to show statistical significance.
Table. Good Outcome With Endovascular Therapy or Control Under General Anesthetic vs Conscious Sedationa
The DEFUSE 3 trial, reported at last month's International Stroke Conference (ISC) 2018 and simultaneously published in the New England Journal of Medicine, showed a large benefit of removing the clot by thrombectomy in patients presenting with a large-vessel occlusion 6 to 16 hours after stroke onset and still having salvageable brain tissue identified on perfusion imaging.
However, results of subgroup analysis suggest that this benefit is greatly curtailed in patients receiving the procedure under general anesthesia.
"I would recommend from these results that general anesthesia should be avoided if possible in patients having endovascular therapy for stroke," said Maarten Lansberg, MD, Stanford University Stroke Center, California, during his presentation here, also at ISC 2018.
"We tried to discourage general anesthesia in this trial because of prior data suggesting worse outcomes with this approach, but some sites prefer to use general anesthesia. So we still had 28% of our patients treated that way, and the other 72% received conscious sedation," Dr Lansberg noted.
When the patients treated with thrombectomy under conscious sedation were compared with the control group, there was a larger benefit and it was significant.
But when patients in the thrombectomy group who received the procedure under general anesthesia were compared with the control group, the benefit was much smaller and not significant, Dr Lansberg reported. However, he cautioned that the sample size was small, so it would be difficult to show statistical significance.
| Type of Anesthesia | Endovascular Therapy (%) | Control (%) | Relative Risk (95% Confidence Interval) |
|---|---|---|---|
| General anesthesia (n = 26) | 23 | 17 | 1.4 (0.6 - 3.2) |
| Conscious sedation (n = 66) | 53 | 17 | 3.2 (1.9 - 5.3) |
| aGood outcome was defined as a modified Rankin Scale score of 0 to 2. | |||
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