Sarraj Amrou, Blackburn Spiros, Abraham Michael G, Hussain Muhammad S, Ortega-Gutierrez Santiago, Chen Michael, Kasner Scott E, Churilov Leonid, Sitton Clark W, Pujara Deep K, Sundararajan Sophia, Hu Yin C, Herial Nabeel A, Budzik Ronald F, Hicks William J, Vora Nirav, Arenillas Juan F, Alfonso Mercedes De Lara, Ramos Araque Maria E, Tsai Jenny P, Abdulrazzak Mohammed A, Kozak Osman, Yan Bernard, Mitchell Peter J, Cordato Dennis J, Manning Nathan W, Cheung Andrew, Hanel Ricardo A, Aghaebrahim Amin N, Wu Teddy Y, Portela Pere Cardona, Merchán Andres J Paipa, Gandhi Chirag D, Al-Mufti Fawaz, Samaniego Edgar A, Maali Laith, Qureshi Abed, Lechtenberg Colleen G, Slavin Sabreena, Rosterman Lee, Gibson Daniel, Wallace Adam N, Sahlein Daniel, Pérez de la Ossa Natalia, Hernández Pérez Maria, Schaafsma Joanna D, Blasco Jordi, Renú Arturo, Sangha Navdeep, Warach Steven, Kleinig Timothy J, Mullen Michael, Elijovich Lucas, Shaker Faris, Al-Shaibi Faisal K, Johns Hannah, Duncan Kelsey R, Opaskar Amanda, Popovic Marc J, Altose Michael, Ray Abhishek, Xiong Wei, Sunshine Jeffrey, DeGeorgia Michael, Nguyen Thanh N, Fifi Johanna T, Tjoumakaris Stavropoula, Jabbour Pascal, Pereira Vitor Mendes, Lansberg Maarten G, Albers Greg W, Sila Cathy, Bambakidis Nicholas, Davis Stephen, Wechsler Lawrence, Hill Michael D, Grotta James C, Ribo Marc, Hassan Ameer E, Campbell Bruce C
University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH.
McGovern Medical School at UTHealth, Houston, TX.
Neurology. 2025 Jul 22;105(2):e213819. doi: 10.1212/WNL.0000000000213819. Epub 2025 Jun 26.
The association of anesthesia approach during endovascular thrombectomy (EVT) with clinical outcomes in large strokes is unexplored. We aimed to evaluate whether general anesthesia (GA), compared with non-GA, was associated with better functional outcomes in the SELECT2 trial.
In a prespecified secondary analysis of the SELECT2 trial that enrolled patients with large strokes on noncontrast CT (Alberta Stroke Program Early CT Score [ASPECTS] 3-5), CT perfusion/MRI (core volume ≥50 mL), or both, functional outcomes were compared in EVT-treated patients who received GA or non-GA and whether this association was modified by stroke severity (NIH Stroke Scale score), ischemic injury estimates, and collateral status was evaluated. The primary outcome was 90-day functional status (ordinal modified Rankin Scale [mRS]). Secondary outcomes were functional independence (mRS scores 0-2), independent ambulation (mRS scores 0-3), complete dependence or death (mRS scores 5-6), and mortality.
Of 178 EVT patients (median [interquartile range] age 66 [58-75] years, stroke severity 19 [15-23], CT-ASPECTS 4 [3-5], and core volume 101.5 [70-138] mL, 71 women [39.9%]), 104 (58%) received GA. Time from randomization to arterial puncture was longer with GA (40 [23-59] minutes) vs non-GA (27 [18-47] minutes), but procedural duration (GA: 57 [31.5-77] minutes vs non-GA: 49.5 [30-71] minutes) was similar. Successful reperfusion (modified treatment in cerebral infarction [mTICI] score 2b-3) rates were similar (GA 81 (78%) vs non-GA 62 (84%), adjusted relative risk [aRR] 0.91, 95% CI 0.79-1.06). In addition, mRS distribution did not differ between GA and non-GA groups (adjusted generalized odds ratio 1.21, 95% CI 0.86-1.70), as well as independent ambulation (GA: 41% vs non-GA: 34%, aRR 1.22, 95% CI 0.86-1.74) and functional independence (GA: 22% vs non-GA: 18%, aRR 1.32, 95% CI 0.75-2.35). Stroke severity, ASPECTS, ischemic core volume, or collaterals did not modify the association between anesthesia and functional outcome (all -interaction >0.05). Patients experienced systolic blood pressure (SBP) variability ≥40 mm Hg and minimum intraprocedural SBP (<100 mm Hg) more frequently with GA, but this did not modify GA association with functional outcomes (-interaction = 0.77 and 0.89, respectively).
In patients with large core strokes randomized in SELECT2, EVT outcomes did not differ significantly based on anesthesia approach (GA or non-GA) without heterogeneity across stroke severity and size. While GA was associated with higher SBP variability and lower minimum SBP, this did not modify GA association with functional outcomes. While allocation to anesthesia approach was nonrandomized, our findings suggest that optimizing institutional protocols for preferred anesthesia technique, whether GA or non-GA, may enhance EVT procedural outcomes.
ClinicalTrials.gov ID: NCT03876457.
This study provides Class II evidence that in patients presenting within 24 hours with large vessel occlusion strokes undergoing EVT, the 90-day mRS score is comparable in those with or without GA.
血管内血栓切除术（EVT）期间麻醉方式与大面积卒中临床结局之间的关联尚未得到探索。我们旨在评估在SELECT2试验中，与非全身麻醉（GA）相比，全身麻醉（GA）是否与更好的功能结局相关。
在SELECT2试验的一项预先指定的二次分析中，纳入了非增强CT（阿尔伯塔卒中项目早期CT评分[ASPECTS]为3 - 5）、CT灌注/MRI（核心体积≥50 mL）或两者兼具的大面积卒中患者，比较接受GA或非GA的EVT治疗患者的功能结局，并评估这种关联是否因卒中严重程度（美国国立卫生研究院卒中量表评分）、缺血性损伤评估和侧支循环状态而改变。主要结局是90天功能状态（改良Rankin量表[mRS]）。次要结局包括功能独立性（mRS评分0 - 2）、独立行走（mRS评分0 - 3）、完全依赖或死亡（mRS评分5 - 6）以及死亡率。
在178例EVT患者中（年龄中位数[四分位间距]为66[58 - 75]岁，卒中严重程度为19[15 - 23]，CT - ASPECTS为4[3 - 5]，核心体积为101.5[70 - 138]mL，71例女性[39.9%]），104例（58%）接受了GA。从随机分组到动脉穿刺的时间，GA组（40[23 - 59]分钟）比非GA组（27[18 - 47]分钟）更长，但手术持续时间（GA组：57[31.5 - 77]分钟 vs 非GA组：49.5[30 - 71]分钟）相似。成功再灌注（改良脑梗死治疗[mTICI]评分2b - 3）率相似（GA组81例[78%] vs 非GA组62例[84%]，调整后相对风险[aRR]为0.91，95%CI为0.79 - 1.06）。此外，GA组和非GA组之间的mRS分布没有差异（调整后广义优势比为1.21，95%CI为0.86 - 1.70），独立行走情况（GA组：41% vs 非GA组：34%，aRR为1.22，95%CI为0.86 - 1.74）和功能独立性（GA组：22% vs 非GA组：18%，aRR为1.32，95%CI为0.75 - 2.35）也没有差异。卒中严重程度、ASPECTS、缺血核心体积或侧支循环均未改变麻醉与功能结局之间这一关联（所有交互作用>0.05）。GA组患者更频繁出现收缩压（SBP）变异性≥40 mmHg和术中最低SBP（<100 mmHg），但这并未改变GA与功能结局之间的关联（交互作用分别为0.77和0.89）。
在SELECT2试验中随机分组的大面积核心梗死患者中，基于麻醉方式（GA或非GA）的EVT结局在卒中严重程度和大小方面无显著差异，且无异质性。虽然GA与更高的SBP变异性和更低的最低SBP相关，但这并未改变GA与功能结局之间的关联。虽然麻醉方式的分配并非随机，但我们的研究结果表明，优化机构关于首选麻醉技术（无论是GA还是非GA）的方案，可能会改善EVT手术结局。
ClinicalTrials.gov标识符：NCT03876457。
本研究提供了II级证据，即在24小时内出现大血管闭塞性卒中并接受EVT治疗的患者中，有或无GA患者的90天mRS评分相当。
