Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) may recover better after endovascular therapy (EVT) when treated with general anesthesia rather than moderate sedation. These findings were published in JAMA Neurology.

Researchers aimed to determine whether the choice of anesthesia during EVT influences recovery after stroke. The multicenter, parallel-group, open-label trial (ClinicalTrials.gov 

Identifier: NCT03263117) was conducted across 10 US comprehensive stroke centers between July 2018 and August 2023. Adults aged 18 to 90 years who presented within 16 hours of symptom onset from anterior-circulation LVOs (internal carotid, middle cerebral, or anterior cerebral arteries) were randomized 1:1 to receive either general anesthesia or moderate sedation during EVT.

Of 1931 patients screened, 260 were randomized (mean age, 66.8 years; 52% men). The primary 90-day analysis included 120 participants per group after exclusions. Baseline characteristics were balanced between groups. The median National Institutes of Health Stroke Scale score was 15 (IQR, 11–19), and most patients had prestroke modified Rankin Scale (mRS) scores of 0 to 1. Common comorbidities included hypertension, diabetes, and atrial fibrillation. Stroke onset to EVT occurred within 6 hours in 69% of participants.

 

[A]mong patients with AIS due to LVO who underwent EVT, GA was associated with a better procedural reperfusion and a higher likelihood of functional independence at 3 months compared with moderate sedation.

At 90 days, the distribution of mRS scores slightly favored general anesthesia over sedation (odds ratio [OR], 1.22; 95% credible interval [CrI], 0.79-1.87), corresponding to an 81% posterior probability of superiority. Functional independence (mRS, 0-2) was achieved by 48% of patients who received general anesthesia and 39% who received sedation (relative risk [RR], 1.20; 95% CrI, 0.90-1.66), with an 89% posterior probability that general anesthesia improved outcomes. Successful reperfusion occurred in 97% of the general anesthesia group and 95% of the sedation group.

Symptomatic intracerebral hemorrhage occurred in 0.8% of patients under general anesthesia and 2.4% under sedation (RR, 0.71; 95% CrI, 0.23-2.16), suggesting a possible safety advantage. The researchers noted that the time from angiography suite entry to groin puncture was about 4 minutes longer with general anesthesia, but this delay did not offset potential benefits.

Study limitations include an open-label design, small sample size, and variability across centers.

“[A]mong patients with AIS due to LVO who underwent EVT, [general anesthesia] was associated with a better procedural reperfusion and a higher likelihood of functional independence at 3 months compared with moderate sedation,” the study authors concluded.