Anesthetic management for large vessel occlusion acute ischemic stroke with tandem lesions.
Endovascular therapy (EVT) stands as an established and effective intervention for acute ischemic stroke in patients harboring tandem lesions (TLs). However, the optimal anesthetic strategy for EVT in TL patients remains unclear. This study aims to evaluate the impact of distinct anesthetic techniques on outcomes in acute ischemic stroke patients presenting with TLs.
Patient-level data, encompassing cases from 16 diverse centers, were aggregated for individuals with anterior circulation TLs treated between January 2015 and December 2020. A stratification based on anesthetic technique was conducted to distinguish between general anesthesia (GA) and procedural sedation (PS). Multivariable logistic regression models were built to discern the association between anesthetic approach and outcomes, including the favorable functional outcome defined as 90-day modified Rankin Score (mRS) of 0-2, ordinal shift in mRS, symptomatic intracranial hemorrhage (sICH), any hemorrhage, successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b), excellent recanalization (mTICI 3), first pass effect (FPE), early neurological improvement (ENI), door-to-groin and recanalization times, intrahospital mortality, and 90-day mortality.
Among 691 patients from 16 centers, 595 patients (GA 38.7%, PS 61.3%) were included in the final analysis. There were no significant differences noted in the door-to-groin time (80 (46-117.5) mins vs 54 (21-100), P=0.607) and groin to recanalization time (59 (39.5-85.5) mins vs 54 (38-81), P=0.836) among the groups. The odds of a favorable functional outcome (36.6% vs 52.6%; adjusted OR (aOR) 0.56, 95% CI 0.38 to 0.84, P=0.005) and a favorable shift in the 90-day mRS (aOR 0.71, 95% CI 0.51 to 0.99, P=0.041) were lower in the GA group. No differences were noted for sICH (3.9% vs 4.7%, P=0.38), successful recanalization (89.1% vs 86.5%, P=0.13), excellent recanalization (48.5% vs 50.3%, P=0.462), FPE (53.6% vs 63.4%, P=0.05), ENI (38.9% vs 38.8%, P=0.138), and 90-day mortality (20.3% vs 16.3%, P=0.525). An interaction was noted for favorable functional outcome between the type of anesthesia and the baseline Alberta Stroke Program Early CT Score (ASPECTS) (P=0.033), degree of internal carotid artery (ICA) stenosis (P<0.001), and ICA stenting (P<0.001), and intraparenchymal hematoma between the type of anesthesia and intravenous thrombolysis (P=0.019). In a subgroup analysis, PS showed better functional outcomes in patients with age ≤70 years, National Institutes of Health Stroke Scale (NIHSS) score <15, and acute ICA stenting.
Our findings suggest that the preference for PS not only aligns with comparable procedural safety but is also associated with superior functional outcomes. These results prompt a re-evaluation of current anesthesia practices in EVT, urging clinicians to consider patient-specific characteristics when determining the optimal anesthetic strategy for this patient population.
Farooqui M
，Galecio-Castillo M
，Hassan AE
，Divani AA
，Jumaa M
，Ribo M
，Petersen NH
，Abraham MG
，Fifi JT
，Guerrero WR
，Malik A
，Siegler JE
，Nguyen TN
，Sheth SA
，Yoo AJ
，Linares G
，Janjua N
，Quispe-Orozco D
，Tekle WG
，Sabbagh SY
，Zaidi SF
，Olive Gadea M
，Prasad A
，Qureshi A
，De Leacy RA
，Abdalkader M
，Salazar-Marioni S
，Soomro J
，Gordon W
，Turabova C
，Rodriguez-Calienes A
，Vivanco-Suarez J
，Mokin M
，Yavagal DR
，Jovin TG
，Ortega-Gutierrez S
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Direct endovascular treatment may be more appropriate for patients with good collateral circulation: a retrospective case-control study.
Recent studies have shown that endovascular treatment (EVT) alone is noninferior to the combination of intravenous thrombolysis and EVT (IVT + EVT) in patients with acute ischemic stroke due to large-vessel occlusion (AIS-LVO) in the anterior cerebral circulation. However, some studies report conflicting results suggesting that the benefits of IVT may be limited to specific subgroups. Previous research has established a strong correlation between collateral status and prognosis in patients treated with IVT or EVT. The primary aim of this study was to investigate the impact of collateral status on clinical outcomes in patients receiving EVT alone or IVT + EVT.
We retrospectively collected data from 238 consecutive patients who were diagnosed with AIS-LVO and underwent EVT or IVT + EVT from January 2019 to January 2023. Patients were divided into two groups, based on whether they received IVT prior to EVT. Multivariable ordinal logistic regression with an interaction term was used to assess the impact of collateral circulation on treatment outcomes, including 90-day modified Rankin Scale (mRS) scores, success rate of recanalization, incidence of intracerebral hemorrhage, mortality, embolus migration, and the rate of achieving a modified thrombolysis in cerebral infarction (mTICI) score of 3. To adjust the common odds ratio (OR), we included variables such as gender, age, baseline National Institutes of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and onset-to-puncture time.
Overall, patients with adequate collateral circulation, defined as a regional leptomeningeal collateral score of 17-20 points, demonstrated more favorable 90-day outcomes, including lower mRS score, higher recanalization success rate, and lower rates of intracerebral hemorrhage, mortality, embolus migration, along with higher likelihood of achieving mTICI 3 score. However, the impact of collateral circulation differed between the two groups. In the EVT group, improved collateral circulation was significantly associated with better outcomes [OR: 8.381, 95% confidence interval (CI): 2.120-46.695, P=0.006]. In the IVT + EVT group, improved collateral circulation was linked to better outcomes (OR: 3.157, 95% CI: 1.618-6.541, P=0.001), it was additionally associated with a higher mortality rate (OR: 0.334, 95% CI: 0.145-0.725, P=0.007), increased incidence of embolus escape (OR: 0.359, 95% CI: 0.130-0.894, P=0.033), and a reduced likelihood of mTICI 3 recanalization (OR: 0.460, 95% CI: 0.244-0.844, P=0.014).
Better collateral circulation is associated with favorable 90-day outcomes in both EVT group and IVT + EVT group. However, in the IVT + EVT group better collateral circulation was also linked to a higher rate of mortality, increased incidence of embolus escape, and lower rate of mTICI 3 recanalization. This may suggest that AIS-LVO patients with better collateral circulation could benefit more from EVT alone. Future studies are warranted to confirm these findings.
Chen Z
，Ying Y
，Lu X
，Yu C
，Wang J
，Shao J
，Jia Q
，Li P
，Chen L
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