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Original research
General anesthesia vs procedural sedation for failed NeuroThrombectomy undergoing rescue stenting: intention to treat analysis
  1. Mahmoud H Mohammaden1,2,
  2. Diogo C Haussen1,2,
  3. Alhamza R Al-Bayati3,
  4. Ameer E Hassan4,
  5. Wondwossen Tekle4,
  6. Johanna T Fifi5,
  7. Stavros Matsoukas5,
  8. Okkes Kuybu3,
  9. Bradley A Gross6,
  10. Michael Lang6,
  11. Sandra Narayanan7,
  12. Gustavo M Cortez8,
  13. Ricardo A Hanel8,
  14. Amin Aghaebrahim8,
  15. Eric Sauvageau8,
  16. Mudassir Farooqui9,
  17. Santiago Ortega-Gutierrez10,
  18. Cynthia B Zevallos9,
  19. Milagros Galecio-Castillo9,
  20. Sunil A Sheth11,
  21. Michael Nahhas11,
  22. Sergio Salazar-Marioni11,
  23. Thanh N Nguyen12,
  24. Mohamad Abdalkader13,
  25. Piers Klein12,
  26. Muhammad Hafeez14,
  27. Peter Kan15,
  28. Omar Tanweer16,
  29. Ahmad Khaldi17,
  30. Hanzhou Li18,
  31. Mouhammad Jumaa19,
  32. Syed F Zaidi19,
  33. Marion Oliver19,
  34. Mohamed Salem20,
  35. Jan-Karl Burkhardt20,
  36. Bryan Pukenas21,
  37. Rahul Kumar22,
  38. Michael Lai22,
  39. James E Siegler22,
  40. Sophia Peng23,
  41. Ali Alaraj23,
  42. Raul G Nogueira3
  1. 1Neurology, Emory University, Atlanta, Georgia, USA
  2. 2Marcus Stroke and Neuroscience center, Grady Memorial Hospital, Atlanta, Georgia, USA
  3. 3Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
  4. 4Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
  5. 5Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  6. 6Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
  7. 7Neurology, Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
  8. 8Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
  9. 9Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  10. 10Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  11. 11Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
  12. 12Neurology and Radiology, Boston University School of Medicine, Boston, MA, USA
  13. 13Radiology, Boston University School of Medicine, Boston, MA, USA
  14. 14Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  15. 15Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  16. 16Baylor College of Medicine, Houston, Texas, USA
  17. 17Neurosurgery, WellStar Health System, Marietta, Georgia, USA
  18. 18Department of Neurosciences, WellStar Health System, Marietta, Georgia, USA
  19. 19Neurology, The University of Toledo Medical Center, Toledo, Ohio, USA
  20. 20Neurosurgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
  21. 21Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  22. 22Cooper Hospital University Medical Center, Camden, New Jersey, USA
  23. 23Neurosurgery, University of Illinois Medical Center at Chicago, Chicago, Illinois, USA
  1. Correspondence to Raul G Nogueira, Neurology, UPMC, Pittsburgh, Pennsylvania, USA; raul.g.nogueira{at}icloud.com

Abstract

Background There is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA).

Methods We searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality.

Results Among 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41], P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups.

Conclusions Non-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence.

  • Stroke
  • Angioplasty
  • Thrombectomy

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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Footnotes

  • Twitter @Mahmoudneuro, @diogohaussen, @wondeasa, @StavrosMatsouk, @SandraNarayanan, @CerebrovascLab, @MichaelNahhas, @NguyenThanhMD, @PiersKlein, @PeterKa80460001, @hanssenli

  • Contributors MHM: Study conception, design of the work, statistical analysis, interpretation of data, drafting of the manuscript. RGN: Study conception, design of the work, interpretation of data, critical revision of manuscript, responsible for the overall content as guarantor. Other co-authors: critical revision of manuscript. All authors gave final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • 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 RGN: reports consulting fees for advisory roles with Stryker Neurovascular, Cerenovus, Medtronic, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, Imperative Care and stock options for advisory roles with Brainomix, Viz-AI, Corindus Vascular Robotics, Vesalio, Ceretrieve, Astrocyte and Cerebrotech. DCH is a consultant for Stryker and Vesalio and holds stock options at Viz.AI. ARA is a consultant for Stryker Neurovascular. AEH - 1. Consultant/speaker: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NovaSignal and Vesalio. 2. Principal investigator: COMPLETE study Penumbra, LVO SYNCHRONISE-Viz.ai. 3. Steering committee/publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR. 4. Proctor: Pipeline, FRED, Wingspan, and Onyx. 5. Supported by grants from: GE Healthcare. TNN: Research support from Medtronic, SVIN. SOG reports consulting fees for advisory roles with Stryker Neurovascular, Medtronic and microvention. Research support from Medtronic, Stryker, Microvention, VizAI. AA is consultant for Cerenovus. JB is an Advisory Board Member and consultant for Longeviti Neuro Solutions, and Consultant for Q’Apel Medical. BG is a consultant for Medtronic and Microvention. RAH: is a consultant for Medtronic, Stryker, Cerenovus, Microvention, Balt, Phenox, Rapid Medical, and Q’Apel, advisory board for MiVI, eLum, Three Rivers, Shape Medical and Corindus. Unrestricted research grant from NIH, Interline Endowment, Microvention, Stryker, CNX. Investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RisT, BlinkTBI, and Corindus. ES: reports a speakers’ agreement with Stryker. AA: is on advisory board for iSchema View. PK is a member of the editorial board of JNIS. JF is a member of editorial board of JNIS. JES reports consulting fees from Ceribell, speakers’ bureau for AstraZeneca (both unrelated to the present work).

  • 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.