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Ischemic stroke
Original research
Endovascular therapy of isolated posterior cerebral artery occlusion stroke with and without general anesthesia
  1. Anne Berberich1,
  2. Christian Herweh2,
  3. Muhammad M Qureshi3,
  4. Davide Strambo4,
  5. Patrik Michel4,
  6. Silja Räty5,
  7. Mohamad Abdalkader3,
  8. Pekka Virtanen6,
  9. Marta Olive Gadea7,
  10. Marc Ribo8,9,
  11. Marios-Nikos Psychogios10,
  12. Anh Nguyen10,
  13. Joji B Kuramatsu11,
  14. David Haupenthal11,
  15. Martin Köhrmann12,
  16. Cornelius Deuschl13,
  17. Jordi Kühne Escolà12,
  18. Jelle Demeestere14,
  19. Robin Lemmens14,
  20. Shadi Yaghi15,16,
  21. Liqi Shu15,
  22. Daniel P O Kaiser17,18,
  23. Volker Puetz19,
  24. Johannes Kaesmacher20,
  25. Adnan Mujanovic21,22,
  26. Dominique Cornelius Marterstock23,
  27. Tobias Engelhorn24,
  28. Piers Klein25,
  29. Diogo C Haussen26,
  30. Mahmoud H Mohammaden27,
  31. Bruno Cunha28,
  32. Isabel Fragata28,
  33. Michele Romoli29,
  34. Wei Hu30,
  35. Chao Zhang30,
  36. Stavros Matsoukas31,32,
  37. Johanna T Fifi32,
  38. Sunil A Sheth33,
  39. Sergio Salazar-Marioni34,
  40. João Pedro Marto35,
  41. João Nuno Ramos36,
  42. Milena Miszczuk37,
  43. Christoph Riegler38,39,
  44. Sven Poli40,
  45. Khouloud Poli41,
  46. Ashutosh P Jadhav42,
  47. Shashvat M Desai42,
  48. Volker Maus43,44,
  49. Maximilian Kaeder43,
  50. Adnan H Siddiqui45,
  51. Andre Monteiro46,
  52. Erno Peltola6,
  53. Hesham Masoud47,
  54. Neil Suryadareva48,
  55. Maxim Mokin49,
  56. Shail Thanki50,
  57. Kemal Alpay51,
  58. Riitta Rautio51,
  59. James E Siegler52,
  60. Negar Asdaghi53,
  61. Vasu Saini54,
  62. Italo Linfante55,
  63. Guilherme Dabus56,
  64. Christian H Nolte48,
  65. Eberhard Siebert57,
  66. Markus A Möhlenbruch49,
  67. Urs Fischer58,
  68. Raul G Nogueira59,
  69. Uta Hanning51,
  70. Lukas Meyer52,
  71. Peter Arthur Ringleb53,
  72. Daniel Strbian54,
  73. Thanh N Nguyen60,
  74. Simon Nagel61
    1. 1Neurology, Klinikum der Stadt Ludwigshafen gGmbH Neurologische Klinik, Ludwigshafen, Germany
    2. 2Neuroradiology, Heidelberg University Hospital Head Clinic Center, Heidelberg, Germany
    3. 3Radiology, Boston Medical Center, Boston, Massachusetts, USA
    4. 4Neurology, Lausanne University Hospital Department of Clinical Neurosciences, Lausanne, Switzerland
    5. 5Neurology, HUS Helsinki University Hospital, Helsinki, Finland
    6. 6Radiology, HUS Helsinki University Hospital, Helsinki, Finland
    7. 7Neurology, Hospital Vall d'Hebron, Barcelona, Spain
    8. 8Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
    9. 9Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
    10. 10Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
    11. 11Neurology, Erlangen University Hospital, Erlangen, Germany
    12. 12Department of Neurology, University Hospital Essen, Essen, Germany
    13. 13Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
    14. 14University Hospitals Leuven, Leuven, Belgium
    15. 15Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
    16. 16Rhode Island Hospital, Providence, Rhode Island, USA
    17. 17University Hospital Carl Gustav Carus, Dresden, Germany
    18. 18Technical University Dresden, Dresden, Germany
    19. 19Neurology, Universitatsklinikum Carl Gustav Carus, Dresden, Germany
    20. 20Neuroradiology, University Hospital Bern, Bern, Switzerland
    21. 21Institute for Diagnostic and Interventional Neuroradiology, Inselspital University Hospital Bern, Bern, Switzerland
    22. 22Department of Neurology, University of Bern, Bern, Switzerland
    23. 23Neuroradiology, Erlangen University Hospital, Erlangen, Germany
    24. 24Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
    25. 25Neurology, Radiology, Boston University School of Medicine, Boston, Massachusetts, USA
    26. 26Neurology and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
    27. 27Department of Neurology, Emory University Atlanta, Atlanta, Georgia, USA
    28. 28Neuroradiology, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
    29. 29Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Italy
    30. 30Department of Neurology, University of Science and Technology of China, Hefei, Anhui, China
    31. 31Neurosurgery, The Mount Sinai Hospital, New York, New York, USA
    32. 32Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
    33. 33Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
    34. 34Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
    35. 35Neurology, Hospital de Egas Moniz, Lisboa, Portugal
    36. 36Neurology, Hospital de Egas Moniz Serviço de Neurologia, Lisboa, Portugal
    37. 37Neuroradiology, Charite Medical Faculty Berlin, Berlin, Germany
    38. 38Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin, Berlin, Germany
    39. 39Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
    40. 40Center for Neurology, Eberhard-Karls-Universitat Tubingen Medizinische Fakultat, Tubingen, Germany
    41. 41Neurology & Stroke, University of Tübingen, Tubingen, Germany
    42. 42Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
    43. 43Neuroradiology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
    44. 44Radiology & Neuroradiology, Aschaffenburg-Alzenau Hospital Campus Aschaffenburg, Aschaffenburg, Germany
    45. 45Neurosurgery, University at Buffalo, Buffalo, New York, USA
    46. 46Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
    47. 47Radiology, New York Upstate Medical University, Syracuse, New York, USA
    48. 48Neurology, Center for Stroke Research, Berlin, Germany
    49. 49Neuroradiology, University of Heidelberg, Heidelberg, Germany
    50. 50University of South Florida, Tampa, Florida, USA
    51. 51Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
    52. 52Diagnostic and Interventional Neuroradiology, Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
    53. 53Heidelberg University, Heidelberg, Germany
    54. 54University of Helsinki, Helsinki, Finland
    55. 55Baptist Cardiac and Vascular Institute, Miami, Florida, USA
    56. 56Baptist Health Miami Neuroscience Institute, Miami, Florida, USA
    57. 57Neuroradiology, Charite Universitatsmedizin Berlin, Berlin, Germany
    58. 58Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
    59. 59Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
    60. 60Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
    61. 61Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
    1. Correspondence to Dr Christian Herweh; christian.herweh{at}med.uni-heidelberg.de

    Abstract

    Background The optimal anesthetic strategy for endovascular therapy (EVT) in acute ischemic stroke is still under debate. The aim of this study was to compare the clinical outcomes of patients with isolated posterior cerebral artery (PCA) occlusion stroke undergoing EVT by anesthesia modality with conscious sedation (non-GA) versus general anesthesia (GA).

    Methods Patients from the Posterior CerebraL Artery Occlusion (PLATO) study were analyzed with regard to anesthetic strategy. GA was compared with non-GA using multivariable logistic regression and inverse probability of weighting treatment (IPTW) methods. The primary endpoint was the 90-day distribution of the modified Rankin Scale (mRS) score. Secondary outcomes included functional independence or return to Rankin at day 90, and successful reperfusion, defined as expanded Thrombolysis in Cerebral Infarction (eTICI) 2b to 3. Safety endpoints were symptomatic intracranial hemorrhage and mortality.

    Results Among 376 patients with isolated PCA occlusion stroke treated with EVT, 183 (49%) had GA. The treatment groups were comparable, although the GA group contained more patients with severe stroke and lower posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS). On IPTW analysis, there was no difference between groups with regard to ordinal mRS shift analysis (common OR 0.89, 95% CI 0.53 to 1.51, P=0.67) or functional independence (OR 0.84, 95% CI 0.50 to 1.39, P=0.49). There were greater odds for successful reperfusion with GA (OR 1.70, 95% CI 1.17 to 2.47, P=0.01). Safety outcomes were comparable between groups.

    Conclusion In patients with isolated PCA occlusion undergoing EVT, patients treated with GA had higher reperfusion rates compared with non-GA. Both GA and non-GA strategies were safe and functional outcomes were similar.

    • Intervention
    • Stroke
    • Thrombectomy

    Data availability statement

    Data are available upon reasonable request.

    https://doi.org/10.1136/jnis-2024-021633

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      Data availability statement

      Data are available upon reasonable request.

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      Footnotes

      • X @marcriboj, @daniel_kaiserMD, @adnan_mujanovic, @PiersKlein, @diogohaussen, @Mahmoudneuro, @micheleromoli, @StavrosMatsouk, @andremonteiromd, @JimSiegler, @italolinfante, @FishingNeurons, @NguyenThanhMD

      • AB and CH contributed equally.

      • TNN and SN contributed equally.

      • Correction notice Since this paper was first published, the author name João Marto has been updated to read João Pedro Marto.

      • Contributors NN and SN initiated the collaborative project, implemented the trial for the all countries, monitored data collection for the whole trial, drafted and revised the paper. MMQ wrote the statistical analysis plan, designed data collection tools, cleaned and analyzed the data and drafted and revised the paper. AB and CH cleaned and analyzed the data, drafted and revised the paper. DavS, PM, SR, MA and DanS initiated the collaborative project, wrote the statistical analysis plan, drafted and revised the paper. MO-G, PV, MR, MP, AN, JBK, DH, MarK, CD, JK-E, JD, RL, SY, LS, DPOK, VP, JK, AdM, DCM, TE, PK, DCH, MHM, BC, IF, MR, WH, CZ, SM, JTF, SAS, SS-M, JPM, JNR, MiM, CR, SP, KP, APJ, SMD, VM, MaxK, AHS, AnM, EP, HEM, NS, MaM, ST, KA, RR, JES, NA, VS, IL, GD, CHN, ES, MAM, UF, RGN, UH, LM and PAR collected and drafted and revised the paper.

      • 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 NA reported employment by the American Heart Association. GD reported consultancy for Cerenovus, Penumbra, Route 92, Medtronic, MicroVention, and Stryker and stock holdings in RIST and InNeuroCo. JTF reported consultancy for Cerenovus, MicroVention, and Stryker; Data Safety Monitoring Board (DSMB) for MIVI; and stock holdings in Imperative Care and Sim&Cure. UF reported research support from the Swiss National Science Foundation (SNF), Medtronic, Stryker, Rapid Medical, Penumbra, and Phenox; consultancies for Stryker and CSL Behring; and is on the advisory board for Alexion/Portola, Boehringer Ingelheim, Biogen, and Acthera. UF reports patent US11166738B2. DCH reported consultancy for Vesalio, Cerenovus, Stryker, Brainomix, Poseydon Medical, and Chiesi USA; DSMB from Jacobs Institute; and stock options in Viz AI. CH reported consultancy for Brainomix and Speaker with Stryker. APJ reports consulting with Basking Biosciences; stock options in Gravity Medical Technology; and a patent for a novel stent retriever device licensed to Basking Biosciences. JK reported grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, and Clinical Trials Unit Bern. DPOK reported grants from the Joachim Herz Foundation. JBK reports grants from Alexion Pharmaceuticals, Bayer Healthcare, Sanofi Pasteur, and Biogen Idec. JPM reported consulting from Amicus Therapeutics and Boehringer Ingelheim and Speaker with Boehringer Ingelheim. PM reported grants from the University of Lausanne and Swiss National Science Foundation (SNF). MAM reported grants from Medtronic, Stryker, and MicroVention. MaM reported stock holdings in BrainQ, Serenity Medical, Synchron, and Bendit Technology and consulting from MicroVention, Medtronic, and Johnson & Johnson. SN reported consultancy for Brainomix and is a speaker with Boehringer Ingelheim and Pfizer. TNN reported research support from the Society of Vascular and Interventional Neurology (SVIN) and Medtronic and is on the advisory board with Idorsia. RGN reported consultancy for Biogen, Brainomix, Corindus, Cerenovus, Stryker, Medtronic, Ceretrieve, Anaconda Biomed, Vesalio, Imperative Care, NeuroVasc Technologies, Viz AI, Genentech, Prolong Pharmaceuticals, Perfuze, Phenox, and RapidPulse; stock options in Viz AI, Vesalio, Perfuze, Corindus, Brainomix, and Ceretrieve; and grants from Cerenovus and Stryker. CHN reported compensation (other services) from Novartis, AstraZeneca, Deutsches Zentrum für Herz-Kreislaufforschung, and Deutsches Zentrum für Neurodegenerative Erkrankungen and consultancy for Daiichi Sankyo, Bayer Healthcare, Pfizer, Alexion, and Bristol Myers Squibb. MP reported grants from Penumbra, Rapid Medical, Medtronic, Phenox, Bangerter-Rhyner Stiftung, SNF, Siemens Healthineers, and Stryker Neurovascular; travel support from Medtronic, Siemens Healthineers, Phenox, Penumbra, and Stryker; and consultancy for Siemens Healthineers. VP reported being a lecturer for Daiichi Sankyo. MR reported consultancy for Medtronic MiniMed, Cerenovus, AptaTargets, Stryker, and Philips and stock holdings in Methinks, Nora, and Anaconda Biomed. PAR reported travel support from Bayer and Bristol Myers Squibb and consultancy for Daiichi Sankyo Company and Boehringer Ingelheim. SAS reported consultancy for Imperative Care, Viz AI, and Penumbra; compensation from Motif Neurosciences (other services); and grants from the National Institutes of Health. AHS reported an ownership stake in Integra Lifesciences and Medtronic; consultancy for Cordis, Rapid Medical, MicroVention, Medtronic Vascular, Vassol, IRRAS USA, Boston Scientific, Amnis Therapeutics, Minnetronix Neuro, Canon Medical Systems USA, Cardinal Health 200, Johnson & Johnson–Latin America, Corindus, Penumbra, Apellis Pharmaceuticals, W.L. Gore & Associates, Stryker Corporation, and Viz AI; stock holdings in E8, Spinnaker Medical, Endostream Medical, Cerebrotech Medical Systems, Adona Medical, Bend IT Technologies, Whisper Medical, Neurotechnology Investors, Collavidence, Instylla, Q’Appel Medical, Serenity Medical, Borvo Medical, NeuroRadial Technologies, Sense Diagnostics, Tulavi Therapeutics, Synchron, Neurolutions, Viseon, BlinkTBI, Radical Catheter Technologies, and Truvic Medical; stock options in Viz AI, StimMed, Three Rivers Medical, Silk Road Medical, Imperative Care, CVAID, Cerevatech Medical, InspireMD, and PerFlow Medical; and security holdings in Vastrax, Launch NY, QAS.ai, VICIS, Neurovascular Diagnostics, Cognition Medical, and SongBird Therapy. The other authors report no conflicts.

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

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