Anesthesia vs Procedural Sedation for Mechanical Thrombectomy: Which Is Better?

General anesthesia and procedural sedation during mechanical thrombectomy were associated with similar functional outcomes and complication rates among patients with anterior circulation acute ischemic stroke (AIS). These are the findings of a study published in JAMA Neurology.

The mainstay treatment for anterior circulation large vessel occlusion AIS is endovascular thrombectomy, which can be performed with either general anesthesia or procedural sedation. No formal guidelines have been released on which method should be preferred due to lack of evidence.

This investigator-initiated, multicenter, parallel-group, open-label, randomized clinical trial, the Anesthesia Management in Endovascular Therapy for Ischemic Stroke (AMETIS; ClinicalTrials.gov Identifier: NCT03229148), was conducted at 10 university hospitals in France in 2017 to 2020. Patients (N=273) with occlusion of the intracranial internal carotid artery and/or proximal middle cerebral artery were randomly assigned in a 1:1 ratio to receive general anesthesia (n=135) or procedural sedation (n=138) during mechanical thrombectomy.

The primary outcomes were major periprocedural complications at 7 days and functional independence at 90 days. Functional independence was defined as a modified Rankin Scale (mRS) score of 2 or fewer.

The anesthesia and sedation cohorts comprised:

• patients mean age, 72.0 (SD, 13.2) and 71.3 (SD, 14.4) years,
• 51.9% and 52.2% were women,
• 34.0% and 29.0% had a wake-up or unwitnessed AIS,
• 17.6% and 10.5% had prestroke disability,
• 63.7% and 60.9% had middle cerebral artery M1 segmental occlusion,
• the median time from angiosuite to groin puncture was 11 (IQR, 8-18) and 9 (IQR, 4-15) minutes, and
• 85.2% and 77.6% had successful reperfusion, respectively.

The composite of no major periprocedural complications and functional independence was achieved by 28.2% of the general anesthesia and 36.2% of the procedural sedation cohorts (relative risk [RR], 1.29; 95% CI, 0.91-1.82; P =.15).

Stratified by specific events, the anesthesia and sedation cohorts had similar rates of no periprocedural complications at 7 days (65.9% vs 67.4%; RR, 1.02; 95% CI, 0.86-1.21; P =.80) and functional independence at 90 days (33.3% vs 39.1%; RR, 1.18; 95% CI, 0.86-1.61; P =.32), respectively.

No significant group differences were observed for secondary outcomes of serious adverse events (RR, 0.54; 95% CI, 0.19-1.58; P =.26), progression to malignant stroke (RR, 0.53; 95% CI, 0.20-1.40; P =.19), symptomatic intracranial hemorrhage (RR, 0.93; 95% CI, 0.53-1.64; P =.81), or death at 90 days (RR, 0.90; 95% CI, 0.54-1.51; P =.69). The only exception was that general anesthesia was associated with a higher rate of hypotension than procedural sedation (87.4% vs 44.9%; RR, 0.51; 95% CI, 0.42-0.63; P <.001), respectively.

In the subgroup analysis, patients in both groups achieved the primary composite outcome at similar rates, except that procedural sedation was preferred among the subset of patients aged over 70 years (RR, 1.95; 95% CI, 1.01-3.55).

This study may have been limited, as no standard sedation protocols were included in this study.

Researchers concluded, “[O]ur trial showed that among patients with anterior circulation large-vessel occlusion acute ischemic stroke, general anesthesia and procedural sedation for mechanical thrombectomy were associated with similar rates of functional independence and major periprocedural complications.”

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.