Farooqui Mudassir, Galecio-Castillo Milagros, Hassan Ameer E, Divani Afshin A, Jumaa Mouhammad, Ribo Marc, Petersen Nils H, Abraham Michael G, Fifi Johanna T, Guerrero Waldo R, Malik Amer, Siegler James E, Nguyen Thanh N, Sheth Sunil A, Yoo Albert J, Linares Guillermo, Janjua Nazli, Quispe-Orozco Darko, Tekle Wondwossen G, Sabbagh Sara Y, Zaidi Syed F, Olive Gadea Marta, Prasad Ayush, Qureshi Abid, De Leacy Reade Andrew, Abdalkader Mohamad, Salazar-Marioni Sergio, Soomro Jazba, Gordon Weston, Turabova Charoskhon, Rodriguez-Calienes Aaron, Vivanco-Suarez Juan, Mokin Maxim, Yavagal Dileep R, Jovin Tudor G, Ortega-Gutierrez Santiago
Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA.
J Neurointerv Surg. 2025 Jan 17;17(2):139-146. doi: 10.1136/jnis-2023-021360.
Endovascular therapy (EVT) stands as an established and effective intervention for acute ischemic stroke in patients harboring tandem lesions (TLs). However, the optimal anesthetic strategy for EVT in TL patients remains unclear. This study aims to evaluate the impact of distinct anesthetic techniques on outcomes in acute ischemic stroke patients presenting with TLs.
Patient-level data, encompassing cases from 16 diverse centers, were aggregated for individuals with anterior circulation TLs treated between January 2015 and December 2020. A stratification based on anesthetic technique was conducted to distinguish between general anesthesia (GA) and procedural sedation (PS). Multivariable logistic regression models were built to discern the association between anesthetic approach and outcomes, including the favorable functional outcome defined as 90-day modified Rankin Score (mRS) of 0-2, ordinal shift in mRS, symptomatic intracranial hemorrhage (sICH), any hemorrhage, successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b), excellent recanalization (mTICI 3), first pass effect (FPE), early neurological improvement (ENI), door-to-groin and recanalization times, intrahospital mortality, and 90-day mortality.
Among 691 patients from 16 centers, 595 patients (GA 38.7%, PS 61.3%) were included in the final analysis. There were no significant differences noted in the door-to-groin time (80 (46-117.5) mins vs 54 (21-100), P=0.607) and groin to recanalization time (59 (39.5-85.5) mins vs 54 (38-81), P=0.836) among the groups. The odds of a favorable functional outcome (36.6% vs 52.6%; adjusted OR (aOR) 0.56, 95% CI 0.38 to 0.84, P=0.005) and a favorable shift in the 90-day mRS (aOR 0.71, 95% CI 0.51 to 0.99, P=0.041) were lower in the GA group. No differences were noted for sICH (3.9% vs 4.7%, P=0.38), successful recanalization (89.1% vs 86.5%, P=0.13), excellent recanalization (48.5% vs 50.3%, P=0.462), FPE (53.6% vs 63.4%, P=0.05), ENI (38.9% vs 38.8%, P=0.138), and 90-day mortality (20.3% vs 16.3%, P=0.525). An interaction was noted for favorable functional outcome between the type of anesthesia and the baseline Alberta Stroke Program Early CT Score (ASPECTS) (P=0.033), degree of internal carotid artery (ICA) stenosis (P<0.001), and ICA stenting (P<0.001), and intraparenchymal hematoma between the type of anesthesia and intravenous thrombolysis (P=0.019). In a subgroup analysis, PS showed better functional outcomes in patients with age ≤70 years, National Institutes of Health Stroke Scale (NIHSS) score <15, and acute ICA stenting.
Our findings suggest that the preference for PS not only aligns with comparable procedural safety but is also associated with superior functional outcomes. These results prompt a re-evaluation of current anesthesia practices in EVT, urging clinicians to consider patient-specific characteristics when determining the optimal anesthetic strategy for this patient population.
血管内治疗（EVT）是治疗合并串联病变（TLs）的急性缺血性卒中患者的一种成熟且有效的干预措施。然而，TL患者进行EVT时的最佳麻醉策略仍不明确。本研究旨在评估不同麻醉技术对合并TLs的急性缺血性卒中患者结局的影响。
汇总了2015年1月至2020年12月期间在16个不同中心接受治疗的前循环TLs患者的个体水平数据。根据麻醉技术进行分层，区分全身麻醉（GA）和术中镇静（PS）。构建多变量逻辑回归模型以识别麻醉方法与结局之间的关联，包括定义为90天改良Rankin量表（mRS）评分为0 - 2的良好功能结局、mRS的序数变化、症状性颅内出血（sICH）、任何出血、成功再通（改良脑梗死溶栓（mTICI）评分≥2b）、优异再通（mTICI 3）、首过效应（FPE）、早期神经功能改善（ENI）、门到股动脉时间和再通时间、院内死亡率以及90天死亡率。
在来自16个中心的691例患者中，595例患者（GA占38.7%，PS占61.3%）纳入最终分析。两组之间在门到股动脉时间（80（46 - 117.5）分钟 vs 54（21 - 100）分钟，P = 0.607）和股动脉到再通时间（59（39.5 - 85.5）分钟 vs 54（38 - 81）分钟，P = 0.836）方面未观察到显著差异。GA组良好功能结局的几率（36.6% vs 52.6%；调整后比值比（aOR）0.56，95%置信区间0.38至0.84，P = 0.005）和90天mRS的良好变化（aOR 0.71，95%置信区间0.51至0.99，P = 0.041）较低。在sICH（3.9% vs 4.7%，P = 0.38）、成功再通（89.1% vs 86.5%，P = 0.13）、优异再通（48.5% vs 50.3%，P = 0.462）、FPE（53.6% vs 63.4%，P = 0.05）、ENI（38.9% vs 38.8%，P = 0.138）和9天死亡率（20.3% vs 16.3%）方面未观察到差异。在麻醉类型与基线阿尔伯塔卒中项目早期CT评分（ASPECTS）（P = .033）、颈内动脉（ICA）狭窄程度（P < .001）和ICA支架置入（P < .001）之间，观察到良好功能结局存在交互作用，在麻醉类型与静脉溶栓之间观察到脑实质内血肿存在交互作用（P = 0.019）。在亚组分析中，PS在年龄≤70岁、美国国立卫生研究院卒中量表（NIHSS）评分<15以及急性ICA支架置入的患者中显示出更好的功能结局。
我们的研究结果表明，选择PS不仅与相当的手术安全性一致，而且还与更好的功能结局相关。这些结果促使重新评估EVT中当前的麻醉实践，敦促临床医生在为该患者群体确定最佳麻醉策略时考虑患者的特定特征。
