Mehta Amol, Reddi Preethi, Goldman Daryl, Kellner Christopher P, De Leacy Reade, Fifi Johanna T, Mocco J, Majidi Shahram
Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York , New York , USA.
Neurosurgery. 2025 Jan 1;96(1):104-110. doi: 10.1227/neu.0000000000003031. Epub 2024 Jun 10.
Anesthesia modality for endovascular thrombectomy (EVT) for distal and medium vessel occlusions remains an open question. General anesthesia (GA) may offer advantages over conscious sedation (CS) because of reduced patient movement facilitating catheter navigation, but concerns persist about potential delays and hypotension affecting collateral circulation.
In our prospectively maintained stroke registry from December 2014 to July 2023, we identified patients with distal and medium vessel occlusions defined as M2, M3, or M4 occlusion; A1 or A2 occlusion; and P1 or P2 occlusion, who underwent EVT for acute ischemic stroke. We compared patients who received CS with those who received GA. Primary outcomes were early neurological improvement (ENI), successful reperfusion, first-pass effect, and good outcome at 90 days. Secondary outcomes included intracerebral hemorrhage, subarachnoid hemorrhage, and 90-day mortality.
Of 279 patients, 69 (24.7%) received GA, whereas 193 (69.2%) received CS. CS was associated with higher odds of ENI compared with GA (odds ratio [OR] 2.59, 95% CI [1.04-6.98], P < .05). CS was also associated with higher rates of successful reperfusion (OR 2.33, 95% CI [1.11-4.93], P < .05). CS nonsignificantly trended toward lower rates of mortality (OR 0.51, 95% CI [0.2-1.3], P = .16). No differences in good outcome at 90 days, intracerebral hemorrhage, subarachnoid hemorrhage, or first-pass effect were seen.
The use of CS during EVT seems to be safe and feasible with regard to successful recanalization, hemorrhagic complications, clinical outcome, and mortality. In addition, it may be associated with a higher rate of ENI. Further randomized studies in this specific EVT subpopulation are warranted.
对于远端和中血管闭塞的血管内血栓切除术（EVT），麻醉方式仍是一个悬而未决的问题。全身麻醉（GA）可能比清醒镇静（CS）更具优势，因为患者活动减少有利于导管操作，但对于潜在的延迟和低血压影响侧支循环的担忧依然存在。
在我们前瞻性维护的2014年12月至2023年7月的卒中登记中，我们确定了患有远端和中血管闭塞（定义为M2、M3或M4闭塞；A1或A2闭塞；以及P1或P2闭塞）且因急性缺血性卒中接受EVT的患者。我们将接受CS的患者与接受GA的患者进行了比较。主要结局为早期神经功能改善（ENI）、成功再灌注、首过效应和90天时的良好结局。次要结局包括脑出血、蛛网膜下腔出血和90天死亡率。
在279例患者中，69例（24.7%）接受了GA，而193例（69.2%）接受了CS。与GA相比，CS与更高的ENI几率相关（优势比[OR]2.59，95%置信区间[CI][1.04 - 6.98]，P <.05）。CS还与更高的成功再灌注率相关（OR 2.33，95% CI[1.11 - 4.93]，P <.05）。CS的死亡率有降低趋势但无统计学意义（OR 0.51，95% CI[0.2 - 1.3]，P =.16）。在90天时的良好结局、脑出血、蛛网膜下腔出血或首过效应方面未观察到差异。
在EVT期间使用CS在成功再通、出血并发症、临床结局和死亡率方面似乎是安全可行的。此外，它可能与更高的ENI率相关。有必要在这个特定的EVT亚组中进行进一步的随机研究。
