Introduction: Despite randomized controlled trials and new AHA/ASA guidelines for thrombectomy in anterior circulation acute ischemic large vessel stroke, there is insufficient data regarding the practice of general anesthesia or conscious sedation in the real world. This series of modern standard-of-care mechanical thrombectomy cases evaluates the effect of anesthesia or sedation on procedural parameters and on clinical outcomes.

Methods: A cohort of 60 patients undergoing endovascular thrombectomy procedures for anterior circulation large vessel occlusion with ASPECTS > 6 and presenting within six hours from last-known-well was prospectively collected. The time to interventional suite, to puncture, and to revascularization and procedure duration and quality of revascularization (m-TICI) were reviewed. Clinical outcome was measured using long-term mRS as the primary outcome, but also evaluating mRS and NIHSS at discharge.

Results: In the sixty patients, six patients were intubated for overall medical management prior to the thrombectomy, and thirty-one were intubated specifically for the thrombectomy procedure. The procedure start and revascularization were accomplished about 20 minutes and 27 minutes faster, respectively, with conscious sedation, but this was not statistically significant (p = 0.09 and 0.08). There was no increase in the duration of the procedure (p=0.3). Patients under sedation had a lower NIHSS (17 [9-20] GA vs. 10 [2-18] sedation, p=0.03) and mRS (p=0.02) at discharge. Further analysis accounting for the side of the stroke and excluding patients who were intubated for comorbid conditions and using a matched set with NIHSS =20 to create comparable baseline cohorts continued to demonstrate a better mRS at discharge (p=0.03 in shift analysis, and dichotomized mRS 0-2 proportion of 50% with sedation vs. 17% with intubation).

Conclusions: General anesthesia did not significantly change technical parameters of treatment, and use of conscious sedation was associated with a better clinical outcome at discharge, although this difference was not sustained at follow-up.

Patient Care: This could serve as an example for attendees to evaluate the workflow at their institutions to initiate multidisciplinary changes in patient management during acute stroke.

Learning Objectives: Understand the current evidence regarding differences in outcomes with general anesthesia and conscious sedation. Case-by-case considerations for intubation of an acute stroke patient. Consider the equivalent effectiveness and efficiency of thrombectomy with general anesthesia and with sedation.

References: 1. Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al.: A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. N Engl J Med 372:141217070022009, 2014 2. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al.: Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. N Engl J Med 372:150211090353006, 2015 3. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al.: Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372:1019–30, 2015 4. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al.: Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. N Engl J Med 372:150417035025009, 2015 5. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, et al.: 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment. Stroke 46:3020–3035, 2015 6. Saver JL, Goyal M, Bonafe A, Diener H-C, Levy EI, Pereira VM, et al.: Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372:2285–95, 2015