John Seby, Thebo Umera, Gomes Joao, Saqqur Maher, Farag Ehab, Xu Jijun, Wisco Dolora, Uchino Ken, Hussain Muhammad S
Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA.
Cerebrovasc Dis. 2014;38(4):262-7. doi: 10.1159/000368216. Epub 2014 Nov 13.
Recent studies have shown that intra-arterial recanalization therapy (IAT) for acute ischemic stroke (AIS) is associated with worse clinical outcomes when performed under general anesthesia (GA) compared to local anesthesia, with or without conscious sedation. The reasons for this association have not been systematically studied.
We retrospectively reviewed 190 patients who underwent IAT for anterior circulation AIS from January 2008 to December 2012 at our institution. Baseline demographics, vessels involved, acute stroke treatment including intravenous tissue type plasminogen activator (tPA) use, use of GA vs. monitored anesthesia care (MAC), location of thrombus, recanalization grade, radiologic post-procedural intracerebral hemorrhage, and 30-day outcomes were collected. Relevant clinical time points were recorded. Detailed intra-procedural hemodynamics including maximum/minimum heart rate, systolic blood pressure (BP), diastolic BP, mean BP, use of pressors and episodes of hypotension were collected. Our study's outcomes were as follows: in-hospital mortality, 30-day good outcome (mRS ≤2), successful recanalization and radiologic post-procedural intracerebral hemorrhage.
Ninety-one patients received GA and 99 patients received MAC. There was no significant difference in the NIHSS score between the two groups but the GA group had a higher number of ICA occlusions (31.9 vs. 18.2%, p = 0.043). The time from the start of anesthesia to incision (23.0 ± 12.5 min vs. 18.7 ± 11.3 min, p = 0.020) and the time from the start of anesthesia to recanalization (110 ± 57.2 vs. 92.3 ± 43.0, p = 0.045) was longer in the GA group. The time from incision to recanalization was not significantly different between the two groups. mRS 0-2 was achieved in 22.8% of patients in the MAC group compared to 14.9% in GA (p = 0.293). Higher mortality was seen in the GA group (25.8 vs. 13.3%, p = 0.040). Successful recanalization (TICI 2b-3) was similar between the GA and MAC (57.8 vs. 48.5%, p = 0.182) groups, but GA had a higher number of parenchymal hematomas (26.3 vs. 10.1%, p = 0.003). There was no difference in the intra-procedural hemodynamic variables between the GA and MAC groups. Anesthesia type was an independent predictor for mortality (along with age and initial NIHSS), and the only independent predictor for parenchymal hematomas, with MAC being protective for both.
Our study has confirmed previous findings of GA being associated with poorer outcomes and higher mortality in patients undergoing IAT for AIS. Detailed analysis of intra-procedural hemodynamics did not reveal any significant difference between the two groups. Parenchymal hematoma was the major driver of the difference in outcomes.
最近的研究表明，与局部麻醉（无论是否联合清醒镇静）相比，急性缺血性卒中（AIS）患者在全身麻醉（GA）下进行动脉内再通治疗（IAT）时，临床结局更差。这种关联的原因尚未得到系统研究。
我们回顾性分析了2008年1月至2012年12月在我院接受前循环AIS的IAT治疗的190例患者。收集了基线人口统计学资料、受累血管、急性卒中治疗情况（包括静脉使用组织型纤溶酶原激活剂（tPA））、GA与监护麻醉（MAC）的使用情况、血栓位置、再通分级、术后影像学脑内出血情况以及30天结局。记录了相关临床时间点。收集了详细的术中血流动力学数据，包括最大/最小心率、收缩压（BP）、舒张压、平均血压、升压药的使用情况以及低血压发作情况。我们研究的结局指标如下：住院死亡率、30天良好结局（改良Rankin量表（mRS）≤2）、成功再通以及术后影像学脑内出血。
91例患者接受GA，99例患者接受MAC。两组间美国国立卫生研究院卒中量表（NIHSS）评分无显著差异，但GA组颈内动脉闭塞的患者数量更多（31.9%对18.2%，p = 0.043）。GA组从麻醉开始到切开的时间（23.0±12.5分钟对18.7±11.3分钟，p = 0.020）以及从麻醉开始到再通的时间（110±57.2对92.3±43.0，p = 0.045）更长。两组间从切开到再通的时间无显著差异。MAC组22.8%的患者达到mRS 0 - 2，而GA组为14.9%（p = 0.293）。GA组的死亡率更高（25.8%对13.3%，p = 0.040）。GA组和MAC组的成功再通率（脑梗死溶栓分级（TICI）2b - 3级）相似（57.8%对48.5%，p = 0.182），但GA组的脑实质血肿数量更多（26.3%对10.1%，p = 0.003）。GA组和MAC组术中血流动力学变量无差异。麻醉方式是死亡率的独立预测因素（与年龄和初始NIHSS一起），也是脑实质血肿的唯一独立预测因素，MAC对两者均有保护作用。
我们研究证实了先前的发现，即GA与接受AIS的IAT治疗患者的较差结局和更高死亡率相关。对术中血流动力学的详细分析未发现两组间有任何显著差异。脑实质血肿是结局差异的主要驱动因素。
