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

TY - JOUR

T1 - 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

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 - HERMES collaborators

AU - Buhk, Jan-Hendrik

AU - Thomalla, Götz

AU - Cheng, Bastian

AU - Hoppe, Julia

AU - Goebell, Einar

AU - Holst, Brigitte

AU - Grzyska, Ulrich

N1 - Copyright © 2018 Elsevier Ltd. All rights reserved.

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.

KW - Aged

KW - Aged, 80 and over

KW - Anesthesia, General

KW - Brain Ischemia

KW - Female

KW - Humans

KW - Male

KW - Middle Aged

KW - Outcome and Process Assessment (Health Care)

KW - Randomized Controlled Trials as Topic

KW - Stroke

KW - Thrombectomy

KW - Journal Article

KW - Meta-Analysis

U2 - 10.1016/S1474-4422(17)30407-6

DO - 10.1016/S1474-4422(17)30407-6

M3 - SCORING: Journal article

C2 - 29263006

VL - 17

SP - 47

EP - 53

JO - LANCET NEUROL

JF - LANCET NEUROL

SN - 1474-4422

IS - 1

ER -