In Endovascular Therapy for Stroke, Monitored Anesthesia Is Safe, Effective

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Monitored anesthesia has been associated with complications from patient movement.
Monitored anesthesia has been associated with complications from patient movement.

Monitored anesthesia care (MAC) is as safe and effective as general anesthesia for endovascular therapy for acute posterior circulation stroke, according to results from a retrospective, case-control study published in JAMA Neurology.

Endovascular therapy is considered first-line treatment for early-presenting proximal anterior circulation occlusions; however, there is no consensus on whether general anesthesia with intubation or MAC is ideal for stroke endovascular therapy. The investigators note that conscious sedation is associated with a perceived risk for complications from possible patient movement. However, there is also a risk for decreased blood pressure associated with general anesthesia.

Ashutosh P. Jadhav, MD, PhD, from the University of Pittsburgh Medical Center in Pennsylvania, and colleagues investigated the clinical and angiographic outcomes in patients presenting with vertebrobasilar occlusion strokes who had MAC vs general anesthesia.

The investigation was a retrospective, matched, case-control study of patients treated with endovascular therapy for vertebrobasilar occlusion strokes at 2 academic institutions. Patients were grouped by either MAC or general anesthesia with elective intubation. Patients were excluded if they required emergent intubation.

In total, 215 patients were identified with posterior circulation strokes, with 39 patients excluded for emergent intubation. Of the remaining patients, 35.8% (n=63) received MAC and 64.2% (n=113) received general anesthesia. Conversion from MAC to general anesthesia was required in 13% of the cases (n=8).

Analysis was conducted on 61 matched pairs, with good balance between the groups for baseline characteristics. No significant difference in the 90-day modified Rankin Scale score for the MAC group was observed compared with in the elective general anesthesia group (MAC odds ratio [OR], 1.52; 95% CI, 0.80-2.90; P =.19).

Further, the authors found no significant differences among the groups for reperfusion success rate, parenchymal hematomas, wire perforation, good outcome, or 90-day mortality rate. Neither group was associated with good outcome after multivariate conditional logistic regression (MAC OR, 1.60; 95% CI, 0.73-3.53; P =.24).

The retrospective design and small sample size were significant limitations of the study, and the results would need to be confirmed with a randomized clinical trial, the investigators noted.

"We report what is, to our knowledge, the largest series of patients undergoing ET for posterior circulation with MAC and demonstrate that MAC is feasible and appears to be as safe and effective as GA. Additionally, we found comparable rates of recanalization and procedure times in the GA and MAC groups," they concluded.

Disclosures: Dr Jovin and Dr Nogueira reported multiple disclosures related to medical device companies.

Reference

Jadhav AP, Bouslama M, Aghaebrahim A, et al. Monitored anesthesia care vs intubation for vertebrobasilar stroke endovascular therapy [published online April 10, 2017]. JAMA Neurol. doi: 10.1001/jamaneurol.2017.0192

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