Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

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Abstract

Background General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding Medtronic.

Original languageEnglish (US)
Pages (from-to)47-53
Number of pages7
JournalThe Lancet Neurology
Volume17
Issue number1
DOIs
StatePublished - Jan 2018

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Thrombectomy
General Anesthesia
Meta-Analysis
Stroke
Odds Ratio
Anesthesia
Endovascular Procedures
Random Allocation

ASJC Scopus subject areas

  • Clinical Neurology

Cite this

@article{707f4bbeb7cd4292a53688aa47d78c9e,
title = "Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data",
abstract = "Background General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30{\%}) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95{\%} CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95{\%} CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95{\%} CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding Medtronic.",
author = "{For the} and Campbell, {Bruce C.V.} and {van Zwam}, {Wim H.} and Mayank Goyal and Menon, {Bijoy K.} and Dippel, {Diederik W.J.} and Demchuk, {Andrew M.} and Serge Bracard and Philip White and Antoni D{\'a}valos and Majoie, {Charles B.L.M.} and {van der Lugt}, Aad and Ford, {Gary A.} and {de la Ossa}, {Natalia P{\'e}rez} and Michael Kelly and Romain Bourcier and Donnan, {Geoffrey A.} and Roos, {Yvo B.W.E.M.} and Bang, {Oh Young} and Nogueira, {Raul G.} and Devlin, {Thomas G.} and {van den Berg}, {Lucie A.} and Fr{\'e}d{\'e}ric Claren{\cc}on and Paul Burns and Jeffrey Carpenter and Berkhemer, {Olvert A.} and Yavagal, {Dileep R.} and Pereira, {Vitor Mendes} and Xavier Ducrocq and Anand Dixit and Helena Quesada and Jonathan Epstein and Davis, {Stephen M.} and Olav Jansen and Marta Rubiera and Xabier Urra and Emilien Micard and Lingsma, {Hester F.} and Olivier Naggara and Scott Brown and Francis Guillemin and Muir, {Keith W.} and {van Oostenbrugge}, {Robert J.} and Saver, {Jeffrey L.} and Jovin, {Tudor G.} and Hill, {Michael D.} and Mitchell, {Peter J.} and Berkhemer, {Olvert A.} and Fransen, {Puck SS} and Debbie Beumer and Dan-Victor Giurgiutiu",
year = "2018",
month = "1",
doi = "10.1016/S1474-4422(17)30407-6",
language = "English (US)",
volume = "17",
pages = "47--53",
journal = "The Lancet Neurology",
issn = "1474-4422",
publisher = "Lancet Publishing Group",
number = "1",

}

TY - JOUR

T1 - Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care

T2 - a meta-analysis of individual patient data

AU - For the

AU - Campbell, Bruce C.V.

AU - van Zwam, Wim H.

AU - Goyal, Mayank

AU - Menon, Bijoy K.

AU - Dippel, Diederik W.J.

AU - Demchuk, Andrew M.

AU - Bracard, Serge

AU - White, Philip

AU - Dávalos, Antoni

AU - Majoie, Charles B.L.M.

AU - van der Lugt, Aad

AU - Ford, Gary A.

AU - de la Ossa, Natalia Pérez

AU - Kelly, Michael

AU - Bourcier, Romain

AU - Donnan, Geoffrey A.

AU - Roos, Yvo B.W.E.M.

AU - Bang, Oh Young

AU - Nogueira, Raul G.

AU - Devlin, Thomas G.

AU - van den Berg, Lucie A.

AU - Clarençon, Frédéric

AU - Burns, Paul

AU - Carpenter, Jeffrey

AU - Berkhemer, Olvert A.

AU - Yavagal, Dileep R.

AU - Pereira, Vitor Mendes

AU - Ducrocq, Xavier

AU - Dixit, Anand

AU - Quesada, Helena

AU - Epstein, Jonathan

AU - Davis, Stephen M.

AU - Jansen, Olav

AU - Rubiera, Marta

AU - Urra, Xabier

AU - Micard, Emilien

AU - Lingsma, Hester F.

AU - Naggara, Olivier

AU - Brown, Scott

AU - Guillemin, Francis

AU - Muir, Keith W.

AU - van Oostenbrugge, Robert J.

AU - Saver, Jeffrey L.

AU - Jovin, Tudor G.

AU - Hill, Michael D.

AU - Mitchell, Peter J.

AU - Berkhemer, Olvert A.

AU - Fransen, Puck SS

AU - Beumer, Debbie

AU - Giurgiutiu, Dan-Victor

PY - 2018/1

Y1 - 2018/1

N2 - Background General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding Medtronic.

AB - Background General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding Medtronic.

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