Comparison of General Anesthesia vs. Conscious Sedation during Endovascular Therapy on Infarct Growth and Clinical Outcomes in Acute Ischemic Stroke

CV
Source: 
Neurosurgery

Previous studies have yielded conflicting results regarding patient outcomes after endovascular therapy for acute ischemic stroke depending on whether general anesthesia (GA) or conscious sedation (CS) was administered. The GOLIATH trial (General or Local Anesthesia in Intra Arterial Therapy) is a single-center, prospective, randomized, blinded end point study of GA vs. CS on infarct growth and functional outcomes.  128 adult patients with acute anterior circulation ischemic stroke who were candidates for endovascular therapy and groin access within 6 hours of ictus/last known normal were randomized to GA or CS.  These patients underwent an 11-minute pre-procedure MRI, and IV tPA was administered when applicable. Exclusion criteria included intubated patients, Glasgow Coma Score < 9 or modified Rankin Score >2, contraindication to MRI, or baseline infarct > 70 mL.  Use of aspiration, stent retriever, or chemical thrombolysis was left to clinician discretion, and concomitant carotid stenting was performed when necessary.  No statistically significant difference was seen in infarct growth between groups.  Successful reperfusion (TICI 2b or 3) was higher in the GA cohort (76.9% vs 60.3%, p =0.04), though time from arrival to the angiography suite to groin puncture was slightly longer in the GA group by an average of 9 minutes.  This was deemed negligible when compared to the time from symptom onset to time to reperfusion between groups, which was not significantly different.  Functionally, GA patients had a shift toward lower mRS at 90 days (OR 1.91, 95%CI, 1.03 – 3.56).  There was no significant difference in mortality or safety end points between GA and CS groups.

Stephen Grupke, MD
Lexington, KY