General vs Nongeneral Anesthesia for Endovascular Thrombectomy in Patients With Large Core Strokes: A Prespecified Secondary Analysis of SELECT2 Trial.

IF 7.7 1区 医学 Q1 CLINICAL NEUROLOGY
Neurology Pub Date : 2025-07-22 Epub Date: 2025-06-26 DOI:10.1212/WNL.0000000000213819
Amrou Sarraj, Spiros Blackburn, Michael G Abraham, Muhammad S Hussain, Santiago Ortega-Gutierrez, Michael Chen, Scott E Kasner, Leonid Churilov, Clark W Sitton, Deep K Pujara, Sophia Sundararajan, Yin C Hu, Nabeel A Herial, Ronald F Budzik, William J Hicks, Nirav Vora, Juan F Arenillas, Mercedes De Lara Alfonso, Maria E Ramos Araque, Jenny P Tsai, Mohammed A Abdulrazzak, Osman Kozak, Bernard Yan, Peter J Mitchell, Dennis J Cordato, Nathan W Manning, Andrew Cheung, Ricardo A Hanel, Amin N Aghaebrahim, Teddy Y Wu, Pere Cardona Portela, Andres J Paipa Merchán, Chirag D Gandhi, Fawaz Al-Mufti, Edgar A Samaniego, Laith Maali, Abed Qureshi, Colleen G Lechtenberg, Sabreena Slavin, Lee Rosterman, Daniel Gibson, Adam N Wallace, Daniel Sahlein, Natalia Pérez de la Ossa, Maria Hernández Pérez, Joanna D Schaafsma, Jordi Blasco, Arturo Renú, Navdeep Sangha, Steven Warach, Timothy J Kleinig, Michael Mullen, Lucas Elijovich, Faris Shaker, Faisal K Al-Shaibi, Hannah Johns, Kelsey R Duncan, Amanda Opaskar, Marc J Popovic, Michael Altose, Abhishek Ray, Wei Xiong, Jeffrey Sunshine, Michael DeGeorgia, Thanh N Nguyen, Johanna T Fifi, Stavropoula Tjoumakaris, Pascal Jabbour, Vitor Mendes Pereira, Maarten G Lansberg, Greg W Albers, Cathy Sila, Nicholas Bambakidis, Stephen Davis, Lawrence Wechsler, Michael D Hill, James C Grotta, Marc Ribo, Ameer E Hassan, Bruce C Campbell
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Secondary outcomes were functional independence (mRS scores 0-2), independent ambulation (mRS scores 0-3), complete dependence or death (mRS scores 5-6), and mortality.</p><p><strong>Results: </strong>Of 178 EVT patients (median [interquartile range] age 66 [58-75] years, stroke severity 19 [15-23], CT-ASPECTS 4 [3-5], and core volume 101.5 [70-138] mL, 71 women [39.9%]), 104 (58%) received GA. Time from randomization to arterial puncture was longer with GA (40 [23-59] minutes) vs non-GA (27 [18-47] minutes), but procedural duration (GA: 57 [31.5-77] minutes vs non-GA: 49.5 [30-71] minutes) was similar. Successful reperfusion (modified treatment in cerebral infarction [mTICI] score 2b-3) rates were similar (GA 81 (78%) vs non-GA 62 (84%), adjusted relative risk [aRR] 0.91, 95% CI 0.79-1.06). 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引用次数: 0

Abstract

Background and objectives: The association of anesthesia approach during endovascular thrombectomy (EVT) with clinical outcomes in large strokes is unexplored. We aimed to evaluate whether general anesthesia (GA), compared with non-GA, was associated with better functional outcomes in the SELECT2 trial.

Methods: In a prespecified secondary analysis of the SELECT2 trial that enrolled patients with large strokes on noncontrast CT (Alberta Stroke Program Early CT Score [ASPECTS] 3-5), CT perfusion/MRI (core volume ≥50 mL), or both, functional outcomes were compared in EVT-treated patients who received GA or non-GA and whether this association was modified by stroke severity (NIH Stroke Scale score), ischemic injury estimates, and collateral status was evaluated. The primary outcome was 90-day functional status (ordinal modified Rankin Scale [mRS]). Secondary outcomes were functional independence (mRS scores 0-2), independent ambulation (mRS scores 0-3), complete dependence or death (mRS scores 5-6), and mortality.

Results: Of 178 EVT patients (median [interquartile range] age 66 [58-75] years, stroke severity 19 [15-23], CT-ASPECTS 4 [3-5], and core volume 101.5 [70-138] mL, 71 women [39.9%]), 104 (58%) received GA. Time from randomization to arterial puncture was longer with GA (40 [23-59] minutes) vs non-GA (27 [18-47] minutes), but procedural duration (GA: 57 [31.5-77] minutes vs non-GA: 49.5 [30-71] minutes) was similar. Successful reperfusion (modified treatment in cerebral infarction [mTICI] score 2b-3) rates were similar (GA 81 (78%) vs non-GA 62 (84%), adjusted relative risk [aRR] 0.91, 95% CI 0.79-1.06). In addition, mRS distribution did not differ between GA and non-GA groups (adjusted generalized odds ratio 1.21, 95% CI 0.86-1.70), as well as independent ambulation (GA: 41% vs non-GA: 34%, aRR 1.22, 95% CI 0.86-1.74) and functional independence (GA: 22% vs non-GA: 18%, aRR 1.32, 95% CI 0.75-2.35). Stroke severity, ASPECTS, ischemic core volume, or collaterals did not modify the association between anesthesia and functional outcome (all p-interaction >0.05). Patients experienced systolic blood pressure (SBP) variability ≥40 mm Hg and minimum intraprocedural SBP (<100 mm Hg) more frequently with GA, but this did not modify GA association with functional outcomes (p-interaction = 0.77 and 0.89, respectively).

Discussion: In patients with large core strokes randomized in SELECT2, EVT outcomes did not differ significantly based on anesthesia approach (GA or non-GA) without heterogeneity across stroke severity and size. While GA was associated with higher SBP variability and lower minimum SBP, this did not modify GA association with functional outcomes. While allocation to anesthesia approach was nonrandomized, our findings suggest that optimizing institutional protocols for preferred anesthesia technique, whether GA or non-GA, may enhance EVT procedural outcomes.

Trial registration information: ClinicalTrials.gov ID: NCT03876457.

Classification of evidence: This study provides Class II evidence that in patients presenting within 24 hours with large vessel occlusion strokes undergoing EVT, the 90-day mRS score is comparable in those with or without GA.

大核心卒中患者血管内血栓切除术的全麻与非全麻:预先指定的SELECT2试验的二次分析
背景和目的:大卒中患者血管内血栓切除术(EVT)麻醉入路与临床结果的关系尚不清楚。在SELECT2试验中,我们的目的是评估全身麻醉(GA)与非全身麻醉相比是否与更好的功能结局相关。方法:在预先指定的SELECT2试验的二次分析中,该试验招募了非对比CT (Alberta卒中计划早期CT评分[ASPECTS] 3-5)、CT灌注/MRI(核心容积≥50 mL)或两者同时进行的大卒中患者,比较了接受GA或非GA的evt治疗患者的功能结局,并评估了这种关联是否受到卒中严重程度(NIH卒中量表评分)、缺血性损伤估计和侧支状态的影响。主要终点是90天的功能状态(普通修正Rankin量表[mRS])。次要结局是功能独立(mRS评分0-2)、独立行走(mRS评分0-3)、完全依赖或死亡(mRS评分5-6)和死亡率。结果:178例EVT患者(中位年龄66[58-75]岁,卒中严重程度19 [15-23],CT-ASPECTS 4[3-5],核心容积101.5 [70-138]mL, 71例女性[39.9%]),104例(58%)接受GA治疗。从随机分组到动脉穿刺的时间,GA组(40[23-59]分钟)比非GA组(27[18-47]分钟)更长,但手术时间(GA: 57[31.5-77]分钟vs非GA: 49.5[30-71]分钟)相似。再灌注成功(改良治疗脑梗死[mTICI]评分为2b-3)率相似(GA 81 (78%) vs非GA 62(84%),校正相对危险度[aRR] 0.91, 95% CI 0.79-1.06)。此外,GA组和非GA组之间的mRS分布没有差异(调整广义优势比1.21,95% CI 0.86-1.70),以及独立行走(GA: 41% vs非GA: 34%, aRR 1.22, 95% CI 0.86-1.74)和功能独立性(GA: 22% vs非GA: 18%, aRR 1.32, 95% CI 0.75-2.35)。卒中严重程度、ASPECTS、缺血性核心容量或侧边并没有改变麻醉与功能结局之间的关联(所有p-相互作用>.05)。患者收缩压(SBP)变异性≥40 mm Hg,术中最小收缩压(p相互作用分别= 0.77和0.89)。讨论:在SELECT2中随机分配的大核心卒中患者中,EVT结果在麻醉方式(GA或非GA)上没有显着差异,在卒中严重程度和大小上没有异质性。虽然GA与较高的收缩压变异性和较低的最小收缩压相关,但这并没有改变GA与功能结局的关联。虽然麻醉方法的分配是非随机的,但我们的研究结果表明,优化首选麻醉技术的机构方案,无论是GA还是非GA,都可能提高EVT的手术结果。试验注册信息:ClinicalTrials.gov ID: NCT03876457。证据分类:本研究提供了II类证据,在24小时内出现大血管闭塞性卒中并进行EVT的患者中,有无GA的90天mRS评分具有可比性。
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来源期刊
Neurology
Neurology 医学-临床神经学
CiteScore
12.20
自引率
4.00%
发文量
1973
审稿时长
2-3 weeks
期刊介绍: Neurology, the official journal of the American Academy of Neurology, aspires to be the premier peer-reviewed journal for clinical neurology research. Its mission is to publish exceptional peer-reviewed original research articles, editorials, and reviews to improve patient care, education, clinical research, and professionalism in neurology. As the leading clinical neurology journal worldwide, Neurology targets physicians specializing in nervous system diseases and conditions. It aims to advance the field by presenting new basic and clinical research that influences neurological practice. The journal is a leading source of cutting-edge, peer-reviewed information for the neurology community worldwide. Editorial content includes Research, Clinical/Scientific Notes, Views, Historical Neurology, NeuroImages, Humanities, Letters, and position papers from the American Academy of Neurology. The online version is considered the definitive version, encompassing all available content. Neurology is indexed in prestigious databases such as MEDLINE/PubMed, Embase, Scopus, Biological Abstracts®, PsycINFO®, Current Contents®, Web of Science®, CrossRef, and Google Scholar.
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