General anesthesia (GA), conscious sedation (CS), and local anesthesia (LA) are used in acute ischemic stroke interventions depending on several factors, including patient status, operator habits, and immediate availability of anesthetic support. In 2008, Mc Donagh et al showed that neurointerventionalists’ preferred modality was general anesthesia, citing elimination of patient’s movements, the perception of increased procedural safety and efficacy, and saving intra-operative time. ¹  Since then, some interventionalists progressively changed their practices, spurred by 3 reports of retrospective data suggesting that general anesthesia may negatively impact outcomes in AIS interventions.^3-5 In 2013, our group conducted a survey on mechanical thrombectomy practices in France that confirmed this tendency, with approximately half of the interventionalists who start the procedure under CS 2. However, the 3 aforementioned studies comparing anesthetic modalities had several limitations, including their retrospective nature, selection bias (patients treated under GA were more likely to have higher NIHSS), inclusion of some occlusion sites only (anterior circulation or MCA), and they obviously predated the availability of the safer and more effective stent-retriever devices.

To provide precise knowledge of the feasibility, efficacy, and safety of mechanical thrombectomy with stent-retriever (Solitaire FR) in patients under conscious sedation, we conducted a prospective study using an intention-to-treat analysis. ⁵ Thirty-six consecutive patients with AIS due to a large artery occlusion were included (within 6 hours of symptom onset for anterior circulation and 8 hours for the posterior circulation) and treated with the stent-retriever while under conscious sedation. Mechanical thrombectomy was feasible in a high percentage of cases (86.1%). Treatment failed due to patient agitation in 8.3% and to vessel tortuosity in 5.6%. Because of the failed procedures, the recanalization rate (77.8%) was lower compared with other stent-retrievers series. Despite this relatively low recanalization rate, at 3 months, a high rate of good clinical outcome (61.1%) and acceptable symptomatic ICH rate (13.8%) and mortality (22.2%) were reported.  Consequently, conscious sedation appeared to be a valuable alternative to general anesthesia in most cases and could be the first choice in patients without agitation or altered consciousness.

To date, we have treated 100 patients under conscious sedation using stent-retrievers, with similar results as previously reported. With this hindsight, we focused on the specific complications that can occur during these procedures and propose to sort eligible patients between each anesthetic modality.⁷ Even if the rate of intubation during or just after the procedure is

low, as well as inhalation, 1 out of 5 patients was agitated during the procedure, emphasizing that the safety of the procedure needs to be ensured by an experienced anesthesiologist, who can rapidly manage untoward events.

Lately, results from comparisons of anesthetic modalities in the North American SOLITAIRE Stent-Retriever Acute Stroke (NASA) Registry have reinforced our findings.⁸ Indeed, in this study analyzing 281 patients, despite identical recanalization rates between LA and GA groups, good neurological outcome (mRS ≤ 2) was achieved in more LA patients, 52.6% vs. 35.6% for GA patients (OR = 1.4, 95% CI: 1.1–1.8, P = 0.01).

To date, no RCT has addressed the question of the potential superiority of conscious sedation (or local anesthesia) upon general anesthesia in term of clinical outcome and safety.

References

1. McDonagh D, Olson DW, Kalia J, et al. Anesthesia and sedation practices among neurointerventionalists during acute ischemic stroke endovascular therapy. Front Neurol 2010;2,118, 10.3389/fneur.2010.00118
2. Soize S, Naggara O, Desal H, et al. Endovascular treatment of acute ischemic stroke in France: a nationwide survey. J Neuroradiol 2014;41:71–79, 10.1016/j.neurad.2013.12.002
3. Abou-Chebl A, Lin R, Hussain MS, et al. Conscious sedation versus general anesthesia during endovascular therapy for anterior circulation stroke: preliminary results from a retrospective, multicenter study. Stroke 2010;41:1175–79, 10.1161/STROKEAHA.109.574129
4. Jumaa MA, Zhang F, Ruiz-Ares G, et al. Comparison of safety and clinical and radiographic outcomes in endovascular acute stroke therapy for proximal middle cerebral artery occlusion with intubation and general anesthesia versus the nonintubated state. Stroke 2010;41:1180–84, 10.1161/STROKEAHA.109.574194
5. Nichols C, Carrozzella J, Yeatts et al. Is periprocedural sedation during acute stroke therapy associated with poorer functional outcomes? J Neurointerv Surg 2010;2:67–70, 1136/jnis.2009.001768
6. Soize S, Kadziolka K, Estrade L, et al. Mechanical thrombectomy in acute stroke: prospective pilot trial of the solitaire FR device while under conscious sedation. AJNR Am J Neuroradiol 2013;34:360–65, 10.3174/ajnr.A3200
7. Benaïssa A, Soize S, Serre I, et al. Technical feasibility of mechanical thrombectomy under conscious sedation and comprehensive evaluation of procedural complications: four years of experience with stent-retriever devices. EJMINT 2014:1436000148,
8. Abou-Chebl A, Zaidat OO, Castonguay AC, et al. North American SOLITAIRE Stent-Retriever Acute Stroke Registry: choice of anesthesia and outcomes. Stroke 2014;45:1396–1401, 10.1161/STROKEAHA.113.003698

 

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