Research in context
Evidence before this study
We searched PubMed for studies in any language examining the association of general anaesthesia (GA) with outcome in stroke patients undergoing endovascular thrombectomy between Jan 1, 2010, and May 31, 2017, using one of the terms “general anesthesia” OR “anesthetic” OR “sedation” with “thrombectomy”. Multiple observational studies showed a worse outcome in patients treated under GA compared with patients who were not treated under GA. Individual randomised trials of thrombectomy versus standard care found conflicting results on the effect of GA, varying between abolition of the thrombectomy treatment effect in MR CLEAN and no effect in THRACE. Three single-centre randomised trials of GA versus conscious sedation found either no difference in functional outcome between groups or a slight benefit of GA.
Added value of this study
To our knowledge, these data from contemporary, high-quality randomised trials form the largest study to date of the association between GA and the benefit of endovascular thrombectomy versus standard care. We found that GA for endovascular thrombectomy, as practised in contemporary clinical care across a wide range of expert centres during the randomised trials, was associated with a worse outcome than that seen when avoiding GA, independent of patient comorbidities. Patients still benefited from thrombectomy compared with standard care when treated under GA.
Implications of all the available evidence
The requirement for GA when the airway is compromised or the patient is agitated, which threatens the quality of revascularisation, should not deter clinicians from pursuing endovascular thrombectomy. The contrast between this analysis and the recent randomised trials comparing GA with conscious sedation suggests that, when GA is medically necessary, close attention should be paid to minimising anaesthetic delays to commence the procedure and maintaining physiological parameters such as blood pressure. A multicentre randomised trial to definitively address these issues is warranted.