1 Affiliated Hospital of Chengdu University Chengdu Sichuan China.
2 Shanxi Provincial People's Hospital Taiyuan Shanxi China.
J Am Heart Assoc. 2019 Jun 18;8(12):e011754. doi: 10.1161/JAHA.118.011754. Epub 2019 Jun 11.
Background Endovascular therapy is the standard of care for severe acute ischemic stroke caused by large-vessel occlusion in the anterior circulation, but there is uncertainty regarding the optimal anesthetic approach during this therapy. Meta-analyses of observational studies suggest that general anesthesia increases morbidity and mortality compared with conscious sedation. We performed a systematic review and meta-analysis of randomized clinical trials to examine the effect of anesthetic strategy during endovascular treatment for acute ischemic stroke. Methods and Results Systematic review and meta-analysis according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines has been registered with the PROSPERO (International Prospective Register of Ongoing Systematic Reviews) ( CRD 42018103684). Medline, EMBASE, and CENTRAL databases were searched through August 1, 2018. Meta-analyses were conducted using a random-effects model to pool odds ratio with corresponding 95% CI . The primary outcome was 90-day functional independence (modified Rankin Scale 0-2). In the results, 3 trials with a total of 368 patients were selected. Among patients with ischemic stroke undergoing endovascular therapy, general anesthesia was significantly associated with higher odds of functional independence (odds ratio 1.87, 95% CI 1.15-3.03, I=17%) and successful recanalization (odds ratio 1.94, 95% CI 1.13-3.3) compared with conscious sedation. However, general anesthesia was associated with a higher risk of 20% mean arterial pressure decrease (odds ratio 10.76, 95% CI 5.25-22.07). There were no significant differences in death, symptomatic intracranial hemorrhage, anesthesiologic complication, intensive care unit length of stay, pneumonia, and interventional complication. Conclusions Moderate-quality evidence suggests that general anesthesia results in significantly higher rates of functional independence than conscious sedation in patients with ischemic stroke undergoing endovascular therapy. Large randomized clinical trials are required to confirm the benefit.
背景 血管内治疗是前循环大血管闭塞所致急性缺血性卒中的标准治疗方法，但对于该治疗过程中的最佳麻醉方法尚存在不确定性。观察性研究的荟萃分析表明，与清醒镇静相比，全身麻醉会增加发病率和死亡率。我们对随机临床试验进行了系统评价和荟萃分析，以检查急性缺血性卒中血管内治疗期间麻醉策略的效果。
方法和结果 本研究按照 PRISMA（系统评价和荟萃分析的首选报告项目）指南进行系统评价和荟萃分析，并在 PROSPERO（国际正在进行的系统评价注册库）（CRD42018103684）中进行了注册。通过 8 月 1 日的 Medline、EMBASE 和 CENTRAL 数据库进行搜索。使用随机效应模型进行荟萃分析，以汇总优势比及其相应的 95%CI。主要结局是 90 天功能独立性（改良 Rankin 量表 0-2 分）。结果，共纳入 3 项试验，总计 368 例患者。在接受血管内治疗的缺血性卒中患者中，与清醒镇静相比，全身麻醉与更高的功能独立性（优势比 1.87，95%CI 1.15-3.03，I=17%）和成功再通（优势比 1.94，95%CI 1.13-3.3）相关。然而，全身麻醉与 20%平均动脉压下降的风险增加相关（优势比 10.76，95%CI 5.25-22.07）。两组在死亡率、症状性颅内出血、麻醉并发症、重症监护病房住院时间、肺炎和介入并发症方面无显著差异。
结论 中等质量证据表明，与清醒镇静相比，全身麻醉可使接受血管内治疗的缺血性卒中患者的功能独立性显著提高。需要进行大型随机临床试验来证实这一益处。
