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  • Local anesthesia as a distinct comparator versus conscious sedation and general anesthesia in endovascular stroke treatment: a systematic review and meta-analysis

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Ischemic stroke
Original research
Local anesthesia as a distinct comparator versus conscious sedation and general anesthesia in endovascular stroke treatment: a systematic review and meta-analysis
  1. Waleed Butt1,
  2. Permesh Singh Dhillon1,2,
  3. Anna Podlasek2,
  4. Luqman Malik1,
  5. Sujit Nair1,
  6. David Hewson3,
  7. Timothy J England4,5,
  8. Robert Lenthall1,
  9. Norman McConachie1
  1. 1 Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
  2. 2 NIHR Nottingham Biomedical Research Centre, Nottingham, Nottinghamshire, UK
  3. 3 Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
  4. 4 Vascular Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
  5. 5 Vascular Medicine, Division of Medical Sciences and GEM, School of Medicine, University of Nottingham, Nottingham, UK
  1. Correspondence to Dr Waleed Butt, Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK; mohammad.butt2{at}nuh.nhs.uk

Abstract

Background The optimal anesthetic modality for endovascular treatment (EVT) in acute ischemic stroke (AIS) is undetermined. Comparisons of general anesthesia (GA) with composite non-GA cohorts of conscious sedation (CS) and local anesthesia (LA) without sedation have provided conflicting results. There has been emerging interest in assessing whether LA alone may be associated with improved outcomes. We conducted a systematic review and meta-analysis to evaluate clinical and procedural outcomes comparing LA with CS and GA.

Methods We reviewed the literature for studies reporting outcome variables in LA versus CS and LA versus GA comparisons. The primary outcome was 90 day good functional outcome (modified Rankin Scale (mRS) score of ≤2). Secondary outcomes included mortality, symptomatic intracerebral hemorrhage, excellent functional outcome (mRS score ≤1), successful reperfusion (Thrombolysis in Cerebral Infarction (TICI) >2b), procedural time metrics, and procedural complications. Random effects meta-analysis was performed on unadjusted and adjusted data.

Results Eight non-randomized studies of 7797 patients (2797 LA, 2218 CS, and 2782 GA) were identified. In the LA versus GA comparison, no statistically significant differences were found in unadjusted analyses for 90 day good functional outcome or mortality (OR=1.22, 95% CI 0.84 to 1.76, p=0.3 and OR=0.83, 95% CI 0.64 to 1.07, p=0.15, respectively) or in the LA versus CS comparison (OR=1.14, 95% CI 0.76 to 1.71, p=0.53 and OR=0.88, 95% CI 0.62 to 1.24, p=0.47, respectively). There was a tendency towards achieving excellent functional outcome (mRS ≤1) in the LA group versus the GA group (OR=1.44, 95% CI 1.00 to 2.08, p=0.05, I2=70%). Analysis of adjusted data demonstrated a tendency towards higher odds of death at 90 days in the GA versus the LA group (OR=1.24, 95% CI 1.00 to 1.54, p=0.05, I2=0%).

Conclusion LA without sedation was not significantly superior to CS or GA in improving outcomes when performing EVT for AIS. However, the quality of the included studies impaired interpretation, and inclusion of an LA arm in future well designed multicenter, randomized controlled trials is warranted.

  • thrombectomy
  • stroke
  • brain
  • angiography

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/neurintsurg-2021-017360

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    Data availability statement

    Data are available upon reasonable request.

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    Footnotes

    • WB and PSD contributed equally.

    • Contributors Conception and design: WB and PSD. Acquisition of the data: WB, PSD, and AP. Analysis and interpretation of the data: WB, PSD, and AP. Critical revision of the manuscript: TJE, DH, SN, LM, RL, and NM. Study supervision: RL, TJE, and NM. All authors approved the final version of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.