Background General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding Medtronic.
Bibliographical noteFunding Information:
BCVC reports research support from the National Health and Medical Research Council of Australia (GNT1043242, GNT1035688, GNT1113352), Royal Australasian College of Physicians, Royal Melbourne Hospital Foundation, National Heart Foundation, National Stroke Foundation of Australia and unrestricted grant funding for the EXTEND-IA trial to the Florey Institute of Neuroscience and Mental Health from Covidien (Medtronic). WHvZ reports speaker's honoraria from Stryker and Cerenovus (paid to his institution). MG reports grants and personal fees from Medtronic and Stryker. He has a systems and methods patent for diagnosing strokes licensed to GE Healthcare and a systems of intracranial access patent licensed to Microvention. BKM reports being a member of the Steering and Executive Committee for the ESCAPE trial, which received support from Medtronic and he was a site principal investigator for the SOCRATES trial, which was sponsored by AstraZeneca. He has received honoraria from Penumbra Inc, holds a provisional patent 62/086077 for triaging systems in ischaemic stroke, and received research funding from Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Canada (HSFC), Alberta Innovates—Health Solutions (AIHS), Hotchkiss Brain Institute (HBI), and the Faculty of Medicine, University of Calgary. DWJD reports grants from the Dutch Heart Foundation, AngioCare BV, Medtronic/Covidien/EV3, MEDAC Gmbh/LAMEPRO, Penumbra Inc, Top Medical/Concentric, and Stryker, and his institution received consultancy fees from Stryker, Bracco Imaging, and Servier. AMD reports personal fees from Covidien (Medtronic). PW reports grants from National Institutes for Health Research, the Stroke Association, Medtronic (Covidien), and Codman and has consulted for Microvention Terumo and Codman. AD reports lecture fees, consultancy and advisory board fees from Medtronic Neurovascular (Steering Committee STAR) and an unrestricted grant for the REVASCAT trial from Medtronic (paid to his institution). CBLMM reports honoraria from Stryker (paid to his institution). AvdL reports honoraria from Stryker (paid to his institution). GAF reports grants and personal fees from Medtronic; personal fees from Pfizer, Athersys, AstraZeneca, Lundbeck, Cerevast, and Daiichi Sankyo; personal fees and non-financial support from Boehringer Ingelheim; and grants from Pulse Therapeutics. MK reports grants from the University of Calgary. RGN reports travel support from Stryker for activities related to the DAWN trial. FC reports acting as a consultant for Medtronic, Balt (paid lectures), and Codman Neurovascular (study core lab). OAB reports honoraria from Stryker (paid to his institution). DRY reports consulting for Medtronic Neurovascular as a Steering Committee Member for the SWIFT PRIME trial. VMP reports personal fees from Medtronic. SMD reports lecture fees from Covidien (Medtronic) and advisory board membership for Boehringer Ingelheim. SBro reports statistical consulting fees from the University of Calgary and acts as consultant for Medtronic. KWM has acted as a consultant for Medtronic and Boehringer Ingelheim. The University of Glasgow received grant support for the PISTE trial from Medtronic and Codman as well grants from the Stroke Association (TSA 2011/06) and the National Institute of Health Research (NIHR) Health Technology Assessment programme (HTA 14.08.47). JLS has acted as a scientific consultant regarding trial design and conduct for Medtronic. TGJ has consulted for Codman Neurovascular and Neuravi; holds stock in Silk Road, Anaconda, Route 92, and Blockade; received travel expenses from Stryker as primary investigator of the DAWN trial and from Fundacio Ictus related to the REVASCAT and RACECAT trials. MDH reports unrestricted grant funding for the ESCAPE trial and HERMES collaboration to University of Calgary from Covidien (Medtronic), and active or in-kind support consortium of public or charitable sources (Heart & Stroke Foundation, Alberta Innovates Health Solutions, Alberta Health Services) and the University of Calgary (Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, and Calgary Stroke Program). He has received personal fees from Merck, non-financial support from Hoffmann-La Roche Canada Ltd, has a Systems and Methods for Assisting in Decision-Making and Triaging for Acute Stroke Patients patent pending at the US Patent Office, number 62/086,077 and owns stock in Calgary Scientific Incorporated, a company that focuses on medical imaging software. PJM reports unrestricted grant funding for the EXTEND-IA trial to the Florey Institute of Neuroscience and Mental Health from Covidien (Medtronic), has served as an unpaid consultant to Codman Johnson and Johnson; his organisation has received unrestricted research funding and grants from Codman Johnson and Johnson, Medtronic, and Stryker. All other authors declare no competing interests.
© 2018 Elsevier Ltd