Wang Arthur, Stellfox Madison, Moy Fred, Abramowicz Apolonia E, Lehrer Rachel, Epstein Rivkah, Eiden Nicole, Aquilina Amy, Pednekar Noorie, Brady Glenn, Wecksell Matthew, Cooley John, Santarelli Justin, Stiefel Michael F
Department of Neurosurgery, Division of Cerebrovascular and Endovascular Neurosurgery, New York Medical College, Valhalla, New York, USA; Westchester NeuroVascular Institute, Westchester Medical Center, Valhalla, New York, USA.
Department of Neurosurgery, Division of Cerebrovascular and Endovascular Neurosurgery, New York Medical College, Valhalla, New York, USA.
World Neurosurg. 2017 Mar;99:638-643. doi: 10.1016/j.wneu.2016.12.064. Epub 2016 Dec 23.
Recent randomized trials have demonstrated that endovascular therapy improves outcomes in patients with an acute ischemic stroke from a large vessel occlusion. Subgroup analysis of the Multicenter Randomized CLinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN) study found that patients undergoing general anesthesia (GA) for the procedure did worse than those with nongeneral anesthesia (non-GA). Current guidelines now suggest that we consider non-GA over GA, without large, randomized trials specifically designed to address this issue. We sought to review our experience and outcomes in a program where we routinely use GA in patients undergoing mechanical thrombectomy with similar techniques.
Patients with anterior circulation strokes who received intravenous tissue plasminogen activator (IV-tPA) and endovascular stroke therapy were included in the analysis. The National Institutes of Health Stroke Scale (NIHSS) on admission and discharge and modified Rankin scale scores at discharge were recorded and compared with the outcome measurements of MR CLEAN.
Sixty patients were identified: 39 males and 21 females with a mean age of 62 (range of 29-88). Forty-seven patients were transferred from outside primary stroke centers, while 13 patients presented directly to our institution. Median NIHSS on admission was 15. The median time of symptom onset to endovascular therapy was 265 minutes, with an interquartile range of 81 minutes. Using the thrombolysis in cerebral infarction (TICI) scale, recanalization of TICI 2b-3 was achieved in 76.4% of recorded patients (42/55 recorded). At discharge, mortality was 16.7% (10/60), median NIHSS was 5, and 38.3% (23/60) of patients had a modified Rankin Scale score of 0-2.
General anesthesia does not worsen outcome in patients undergoing mechanical thrombectomy when compared to historical subgroups. Despite a longer time from symptom onset to treatment, our outcomes for patients receiving GA compare favorably to the GA and non-GA groups in MR CLEAN.
近期的随机试验表明，血管内治疗可改善因大血管闭塞导致急性缺血性卒中患者的预后。荷兰急性缺血性卒中血管内治疗多中心随机临床试验（MR CLEAN）的亚组分析发现，接受该手术全身麻醉（GA）的患者比未接受全身麻醉（非GA）的患者预后更差。目前的指南现建议，在没有专门针对此问题设计的大型随机试验的情况下，我们应优先考虑非GA而非GA。我们试图回顾我们在一个项目中的经验和结果，在该项目中，我们对接受机械取栓术的患者常规使用GA，且技术相似。
分析纳入接受静脉注射组织纤溶酶原激活剂（IV-tPA）和血管内卒中治疗的前循环卒中患者。记录入院和出院时的美国国立卫生研究院卒中量表（NIHSS）以及出院时的改良Rankin量表评分，并与MR CLEAN的结果测量进行比较。
共确定60例患者：39例男性和21例女性，平均年龄62岁（范围29 - 88岁）。47例患者从外部初级卒中中心转诊而来，13例患者直接到我们机构就诊。入院时NIHSS中位数为15。症状发作至血管内治疗的中位时间为265分钟，四分位间距为81分钟。使用脑梗死溶栓（TICI）量表，76.4%的记录患者（42/55例记录）实现了TICI 2b - 3级再通。出院时，死亡率为16.7%（10/60），NIHSS中位数为5，38.3%（23/60）的患者改良Rankin量表评分为0 - 2。
与历史亚组相比，全身麻醉在接受机械取栓术的患者中并不会使预后恶化。尽管从症状发作到治疗的时间更长，但我们接受GA治疗患者的结果与MR CLEAN中的GA组和非GA组相比具有优势。
