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Chabanne R, Geeraerts T, Begard M, Balança B, Rapido F, Degos V, Tavernier B, Molliex S, Velly L, Verdonk F, Lukaszewicz AC, Perrigault PF, Albucher JF, Cognard C, Guyot A, Fernandez C, Masgrau A, Moreno R, Ferrier A, Jaber S, Bazin JE, Pereira B, Futier E. Outcomes After Endovascular Therapy With Procedural Sedation vs General Anesthesia in Patients With Acute Ischemic Stroke: The AMETIS Randomized Clinical Trial. JAMA Neurol 2023; 80:474-483. [PMID: 37010829 PMCID: PMC10071397 DOI: 10.1001/jamaneurol.2023.0413] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/03/2023] [Indexed: 04/04/2023]
Abstract
Importance General anesthesia and procedural sedation are common practice for mechanical thrombectomy in acute ischemic stroke. However, risks and benefits of each strategy are unclear. Objective To determine whether general anesthesia or procedural sedation for anterior circulation large-vessel occlusion acute ischemic stroke thrombectomy are associated with a difference in periprocedural complications and 3-month functional outcome. Design, Setting, and Participants This open-label, blinded end point randomized clinical trial was conducted between August 2017 and February 2020, with final follow-up in May 2020, at 10 centers in France. Adults with occlusion of the intracranial internal carotid artery and/or the proximal middle cerebral artery treated with thrombectomy were enrolled. Interventions Patients were assigned to receive general anesthesia with tracheal intubation (n = 135) or procedural sedation (n = 138). Main Outcomes and Measures The prespecified primary composite outcome was functional independence (a score of 0 to 2 on the modified Rankin Scale, which ranges from 0 [no neurologic disability] to 6 [death]) at 90 days and absence of major periprocedural complications (procedure-related serious adverse events, pneumonia, myocardial infarction, cardiogenic acute pulmonary edema, or malignant stroke) at 7 days. Results Among 273 patients evaluable for the primary outcome in the modified intention-to-treat population, 142 (52.0%) were women, and the mean (SD) age was 71.6 (13.8) years. The primary outcome occurred in 38 of 135 patients (28.2%) assigned to general anesthesia and in 50 of 138 patients (36.2%) assigned to procedural sedation (absolute difference, 8.1 percentage points; 95% CI, -2.3 to 19.1; P = .15). At 90 days, the rate of patients achieving functional independence was 33.3% (45 of 135) with general anesthesia and 39.1% (54 of 138) with procedural sedation (relative risk, 1.18; 95% CI, 0.86-1.61; P = .32). The rate of patients without major periprocedural complications at 7 days was 65.9% (89 of 135) with general anesthesia and 67.4% (93 of 138) with procedural sedation (relative risk, 1.02; 95% CI, 0.86-1.21; P = .80). Conclusions and Relevance In patients treated with mechanical thrombectomy for anterior circulation acute ischemic stroke, general anesthesia and procedural sedation were associated with similar rates of functional independence and major periprocedural complications. Trial Registration ClinicalTrials.gov Identifier: NCT03229148.
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Affiliation(s)
- Russell Chabanne
- Département Anesthésie Réanimation et Médecine Périopératoire, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas Geeraerts
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Toulouse, Université Toulouse 3-Paul Sabatier, TONIC, INSERM, Toulouse, France
| | - Marc Begard
- Département Anesthésie Réanimation et Médecine Périopératoire, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, Clermont-Ferrand, France
| | - Baptiste Balança
- Service d’Anesthésie Réanimation, Neuroscience Research Center, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer and Université Lyon 1, Lyon, France
| | - Francesca Rapido
- Service d’Anesthésie Réanimation, Pôle Neurosciences Tête et Cou, Centre Hospitalier Universitaire (CHU) de Montpellier, Hôpital Gui de Chauliac, Montpellier, France
| | - Vincent Degos
- Anesthésie et Neuro-Réanimation chirurgicale Babinski, Département d’Anesthésie-Réanimation, Assistance Publique Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France
| | - Benoit Tavernier
- Pôle d’Anesthésie-Réanimation, Centre Hospitalier Universitaire (CHU) Lille, Université Lille, ULR 2694 – METRICS, Lille, France
| | - Serge Molliex
- Service d’Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Saint-Etienne, Université Jean Monnet, Saint-Etienne, France
| | - Lionel Velly
- Service d’Anesthésie Réanimation, Assistance Publique Hôpitaux de Marseille (AP-HM), Hôpital La Timone and Institut des Neurosciences, MeCA, Aix Marseille Université, Marseille, France
| | - Franck Verdonk
- Département d’Anesthésie-Réanimation, Institut Pasteur, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Paris, France
| | - Anne-Claire Lukaszewicz
- Service d’Anesthésie Réanimation, Neuroscience Research Center, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer and Université Lyon 1, Lyon, France
| | - Pierre-François Perrigault
- Service d’Anesthésie Réanimation, Pôle Neurosciences Tête et Cou, Centre Hospitalier Universitaire (CHU) de Montpellier, Hôpital Gui de Chauliac, Montpellier, France
| | - Jean-François Albucher
- Service de Neurologie Vasculaire, Centre Hospitalier Universitaire (CHU) Toulouse, Université Toulouse 3-Paul Sabatier, TONIC, INSERM, Toulouse, France
| | - Christophe Cognard
- Département de Neuroradiologie Diagnostique et Thérapeutique, Centre Hospitalier Universitaire (CHU) Toulouse, Université Toulouse 3-Paul Sabatier, Toulouse, France
| | - Adrien Guyot
- Département Anesthésie Réanimation et Médecine Périopératoire, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, Clermont-Ferrand, France
| | - Charlotte Fernandez
- Département Anesthésie Réanimation et Médecine Périopératoire, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélie Masgrau
- Direction de la Recherche Clinique et de l’Innovation (DRCI), Secteur Biométrie et Médico-Economie, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
| | - Ricardo Moreno
- Département de Neuroradiologie, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
| | - Anna Ferrier
- Département de Neurologie Vasculaire, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
| | - Samir Jaber
- Service d’Anesthésie Réanimation B (DAR B), Centre Hospitalier Universitaire (CHU) de Montpellier, Hôpital Saint-Eloi, Université de Montpellier, INSERM U-1046, Montpellier, France
| | - Jean-Etienne Bazin
- Département Anesthésie Réanimation et Médecine Périopératoire, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Direction de la Recherche Clinique et de l’Innovation (DRCI), Secteur Biométrie et Médico-Economie, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Département Anesthésie Réanimation et Médecine Périopératoire, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, GRED, CNRS, INSERM U1103, Clermont-Ferrand, France
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Anaesthetic and peri-operative management for thrombectomy procedures in stroke patients. Anaesth Crit Care Pain Med 2023; 42:101188. [PMID: 36599377 DOI: 10.1016/j.accpm.2022.101188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE To provide recommendations for the anaesthetic and peri-operative management for thrombectomy procedure in stroke patients DESIGN: A consensus committee of 15 experts issued from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation, SFAR), the Association of French-language Neuro-Anaesthetists (Association des Neuro-Anesthésistes Réanimateurs de Langue Francaise, ANARLF), the French Neuro-Vascular Society (Société Francaise de Neuro-Vasculaire, SFNV), the French Neuro-Radiology Society (Société Francaise de Neuro-Radiologie, SFNR) and the French Study Group on Haemostasis and Thrombosis (Groupe Français d'Études sur l'Hémostase et la Thrombose, GFHT) was convened, under the supervision of two expert coordinators from the SFAR and the ANARLF. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were required to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. METHODS Four fields were defined prior to the literature search: (1) Peri-procedural management, (2) Prevention and management of secondary brain injuries, (3) Management of antiplatelet and anticoagulant treatments, (4) Post-procedural management and orientation of the patient. Questions were formulated using the PICO format (Population, Intervention, Comparison, and Outcomes) and updated as needed. Analysis of the literature was then conducted and the recommendations were formulated according to the GRADE methodology. RESULTS The SFAR/ANARLF/SFNV/SFNR/GFHT guideline panel drew up 18 recommendations regarding anaesthetic management of mechanical thrombectomy procedures. Due to a lack of data in the literature allowing to conclude with high certainty on relevant clinical outcomes, the experts decided to formulate these guidelines as "Professional Practice Recommendations" (PPR) rather than "Formalized Expert Recommendations". After two rounds of rating and several amendments, a strong agreement was reached on 100% of the recommendations. No recommendation could be formulated for two questions. CONCLUSIONS Strong agreement among experts was reached to provide a sizable number of recommendations aimed at optimising anaesthetic management for thrombectomy in patients suffering from stroke.
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Yang X, Yang J, Sun D, Wang A, Tong X, Jia B, Miao Z. Comparison of predictors of failure of early neurological improvement after successful endovascular treatment for posterior and anterior circulation large vessel occlusion: Data from ANGEL-ACT registry. Interv Neuroradiol 2022:15910199221133164. [PMID: 36266940 DOI: 10.1177/15910199221133164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To identify and compare the predictors of failure of early neurological improvement (fENI)after successful EVT for anterior circulation large vessel occlusion (ACLVO) and posterior circulation LVO (PCLVO). METHODS Subjects were selected from the ANGEL-ACT registry. fENI was defined as unchanged or worsened in National Institutes of Health Stroke Scale score (NIHSS) between admission and 24 h after EVT. Predictors of fENI after successful EVT (mTICI 2b-3) were determined via center-adjusted analyses. Univariable and multivariable comparisons between ACLVO and PCLVO were performed. RESULTS A total of 1447 patients, 1128 were with ACLVO, and 319 were with PCLVO. Among the patients with ACLVO, there were 409 patients (36.3%) with fENI and 719 patients (63.7%) with ENI. We observed that pre-stroke mRS scale score of 2 (odd ratio[OR] 95% confidence interval[CI], 6.93[1.99-24.10], P = 0.002), initial NIHSS score (OR per point[95%CI], 0.97[0.95-0.99], P = 0.012), diabetes (OR[95%CI], 1.56[1.08-2.25], P = 0.017), previous ICH (OR[95%CI] 9.21[1.76-48.15], P = 0.008), local anesthesia (OR[95%CI] 1.63[1.10-2.42], P = 0.014), onset-to-puncture time (OR[95%CI], 1.001[1.000-1.001], P = 0.009), symptomatic ICH (OR[95%CI] 3.90[2.27-6.69], P < 0.001), and continued use of tirofiban within 2 h after EVT (OR[95%CI], 0.69[0.51-0.93], P = 0.014) were independent predictors of fENI of ACLVO after EVT. Among the patients with PCLVO, there were 112 patients (35.1%) with fENI and 207 patients (64.9%) with ENI. In contrast, admission SBP (OR[95%CI], 0.98[0.97-0.99], P = 0.012), and vascular dissection within 2 h after EVT (OR[95%CI], 7.23[1.33-39.13], P = 0.022) were independent predictors of fENI of PCLVO after EVT. CONCLUSION In selected patients, successful EVT can lead to similar outcomes in PCLVO and ACLVO. Some predictors of fENI in both anterior circulation and posterior circulation were identified in our study, which should be highly considered in the clinical practice in LVO patients undergoing EVT.
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Affiliation(s)
- Xinguang Yang
- Department of Neurology, 56713Sun Yat-sen Memorial Hospital, 56713Sun Yat-sen University, Guangzhou, China
| | - Jie Yang
- Department of Neurology, 220741the Second Affiliated Hospital of GuangZhou Medical University, Guangzhou, China
| | - Dapeng Sun
- 571014Department of Interventional Neuroradiology, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- 571014Department of Interventional Neuroradiology, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- 571014Department of Interventional Neuroradiology, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- 571014Department of Interventional Neuroradiology, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Tosello R, Riera R, Tosello G, Clezar CN, Amorim JE, Vasconcelos V, Joao BB, Flumignan RL. Type of anaesthesia for acute ischaemic stroke endovascular treatment. Cochrane Database Syst Rev 2022; 7:CD013690. [PMID: 35857365 PMCID: PMC9298671 DOI: 10.1002/14651858.cd013690.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of mechanical thrombectomy to restore intracranial blood flow after proximal large artery occlusion by a thrombus has increased over time and led to better outcomes than intravenous thrombolytic therapy alone. Currently, the type of anaesthetic technique during mechanical thrombectomy is under debate as having a relevant impact on neurological outcomes. OBJECTIVES To assess the effects of different types of anaesthesia for endovascular interventions in people with acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Specialised Register of Trials on 5 July 2022, and CENTRAL, MEDLINE, and seven other databases on 21 March 2022. We performed searches of reference lists of included trials, grey literature sources, and other systematic reviews. SELECTION CRITERIA: We included all randomised controlled trials with a parallel design that compared general anaesthesia versus local anaesthesia, conscious sedation anaesthesia, or monitored care anaesthesia for mechanical thrombectomy in acute ischaemic stroke. We also included studies reported as full-text, those published as abstract only, and unpublished data. We excluded quasi-randomised trials, studies without a comparator group, and studies with a retrospective design. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria, extracted data, and assessed the risk of bias and the certainty of the evidence using the GRADE approach. The outcomes were assessed at different time periods, ranging from the onset of the stroke symptoms to 90 days after the start of the intervention. The main outcomes were functional outcome, neurological impairment, stroke-related mortality, all intracranial haemorrhage, target artery revascularisation status, time to revascularisation, adverse events, and quality of life. All included studies reported data for early (up to 30 days) and long-term (above 30 days) time points. MAIN RESULTS We included seven trials with 982 participants, which investigated the type of anaesthesia for endovascular treatment in large vessel occlusion in the intracranial circulation. The outcomes were assessed at different time periods, ranging from the onset of stroke symptoms to 90 days after the procedure. Therefore, all included studies reported data for early (up to 30 days) and long-term (above 30 up to 90 days) time points. General anaesthesia versus non-general anaesthesia(early) We are uncertain about the effect of general anaesthesia on functional outcomes compared to non-general anaesthesia (mean difference (MD) 0, 95% confidence interval (CI) -0.31 to 0.31; P = 1.0; 1 study, 90 participants; very low-certainty evidence) and in time to revascularisation from groin puncture until the arterial reperfusion (MD 2.91 minutes, 95% CI -5.11 to 10.92; P = 0.48; I² = 48%; 5 studies, 498 participants; very low-certainty evidence). General anaesthesia may lead to no difference in neurological impairment up to 48 hours after the procedure (MD -0.29, 95% CI -1.18 to 0.59; P = 0.52; I² = 0%; 7 studies, 982 participants; low-certainty evidence), and in stroke-related mortality (risk ratio (RR) 0.98, 95% CI 0.52 to 1.84; P = 0.94; I² = 0%; 3 studies, 330 participants; low-certainty evidence), all intracranial haemorrhages (RR 0.92, 95% CI 0.65 to 1.29; P = 0.63; I² = 0%; 5 studies, 693 participants; low-certainty evidence) compared to non-general anaesthesia. General anaesthesia may improve adverse events (haemodynamic instability) compared to non-general anaesthesia (RR 0.21, 95% CI 0.05 to 0.79; P = 0.02; I² = 71%; 2 studies, 229 participants; low-certainty evidence). General anaesthesia improves target artery revascularisation compared to non-general anaesthesia (RR 1.10, 95% CI 1.02 to 1.18; P = 0.02; I² = 29%; 7 studies, 982 participants; moderate-certainty evidence). There were no available data for quality of life. General anaesthesia versus non-general anaesthesia (long-term) There is no difference in general anaesthesia compared to non-general anaesthesia for dichotomous and continuous functional outcomes (dichotomous: RR 1.21, 95% CI 0.93 to 1.58; P = 0.16; I² = 29%; 4 studies, 625 participants; low-certainty evidence; continuous: MD -0.14, 95% CI -0.34 to 0.06; P = 0.17; I² = 0%; 7 studies, 978 participants; low-certainty evidence). General anaesthesia showed no changes in stroke-related mortality compared to non-general anaesthesia (RR 0.88, 95% CI 0.64 to 1.22; P = 0.44; I² = 12%; 6 studies, 843 participants; low-certainty evidence). There were no available data for neurological impairment, all intracranial haemorrhages, target artery revascularisation status, time to revascularisation from groin puncture until the arterial reperfusion, adverse events (haemodynamic instability), or quality of life. Ongoing studies We identified eight ongoing studies. Five studies compared general anaesthesia versus conscious sedation anaesthesia, one study compared general anaesthesia versus conscious sedation anaesthesia plus local anaesthesia, and two studies compared general anaesthesia versus local anaesthesia. Of these studies, seven plan to report data on functional outcomes using the modified Rankin Scale, five studies on neurological impairment, six studies on stroke-related mortality, two studies on all intracranial haemorrhage, five studies on target artery revascularisation status, four studies on time to revascularisation, and four studies on adverse events. One ongoing study plans to report data on quality of life. One study did not plan to report any outcome of interest for this review. AUTHORS' CONCLUSIONS In early outcomes, general anaesthesia improves target artery revascularisation compared to non-general anaesthesia with moderate-certainty evidence. General anaesthesia may improve adverse events (haemodynamic instability) compared to non-general anaesthesia with low-certainty evidence. We found no evidence of a difference in neurological impairment, stroke-related mortality, all intracranial haemorrhage and haemodynamic instability adverse events between groups with low-certainty evidence. We are uncertain whether general anaesthesia improves functional outcomes and time to revascularisation because the certainty of the evidence is very low. However, regarding long-term outcomes, general anaesthesia makes no difference to functional outcomes compared to non-general anaesthesia with low-certainty evidence. General anaesthesia did not change stroke-related mortality when compared to non-general anaesthesia with low-certainty evidence. There were no reported data for other outcomes. In view of the limited evidence of effect, more randomised controlled trials with a large number of participants and good protocol design with a low risk of bias should be performed to reduce our uncertainty and to aid decision-making in the choice of anaesthesia.
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Affiliation(s)
- Renato Tosello
- Department of Neurointerventional Radiology, Hospital Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
| | - Rachel Riera
- Centre of Health Technology Assessment, Universidade Federal de São Paulo, São Paulo, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde (NEP-Sbeats), Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Caroline Nb Clezar
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jorge E Amorim
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Benedito B Joao
- Division of Anesthesia, Pain, and Intensive Medicine, Department of Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Crosby L, Davis M. Anesthesia for Acute Ischemic Stroke: Updates and Ongoing Debates. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00447-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Riou-Comte N, Zhu F, Cherifi A, Richard S, Nace L, Audibert G, Achit H, Costalat V, Arquizan C, Beaufils O, Consoli A, Lapergue B, Loeb T, Rouchaud A, Macian F, Cailloce D, Biondi A, Moulin T, Desmettre T, Marnat G, Sibon I, Combes X, Lebedinsky AP, Vuillemet F, Kempf N, Pierot L, Moulin S, Lemmel P, Mazighi M, Blanc R, Sabben C, Schluck E, Bracard S, Anxionnat R, Guillemin F, Hossu G, Gory B. Direct transfer to angiosuite for patients with severe acute stroke treated with thrombectomy: the multicentre randomised controlled DIRECT ANGIO trial protocol. BMJ Open 2021; 11:e040522. [PMID: 33722864 PMCID: PMC7970280 DOI: 10.1136/bmjopen-2020-040522] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Mechanical thrombectomy (MT) increases functional independence in patients with acute ischaemic stroke with anterior circulation large vessel occlusion (LVO), and the probability to achieve functional independence decreases by 20% for each 1-hour delay to reperfusion. Therefore, we aim to investigate whether direct angiosuite transfer (DAT) is superior to standard imaging/emergency department-based management in achieving 90-day functional independence in patients presenting with an acute severe neurological deficit likely due to LVO and requiring emergent treatment with MT. METHODS AND ANALYSIS DIRECT ANGIO (Effect of DIRECT transfer to ANGIOsuite on functional outcome in patient with severe acute stroke treated with thrombectomy: the randomised DIRECT ANGIO Trial) trial is an investigator-initiated, multicentre, prospective, randomised, open-label, blinded endpoint (PROBE) study. Eligibility requires a patient ≤75 years, pre-stroke modified Rankin Scale (mRS) 0-2, presenting an acute severe neurological deficit and admitted within 5 hours of symptoms onset in an endovascular-capable centre. A total of 208 patients are randomly allocated in a 1:1 ratio to DAT or standard management. The primary outcome is the rate of patients achieving a functional independence, assessed as mRS 0-2 at 90 days. Secondary endpoints include patients presenting confirmed LVO, patients eligible to intravenous thrombolysis alone, patients with intracerebral haemorrhage and stroke-mimics, intrahospital time metrics, early neurological improvement (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0-1 at 24 hours) and mRS overall distribution at 90 days and 12 months. Safety outcomes are death and intracerebral haemorrhage transformation. Medico-economics analyses include health-related quality of life and cost utility assessment. ETHICS AND DISSEMINATION The DIRECT ANGIO trial was approved by the ethics committee of Ile de France 1. Study began in April 2020. Results will be published in an international peer-reviewed medical journal. TRIAL REGISTRATION NUMBER NCT03969511.
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Affiliation(s)
| | - François Zhu
- Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- INSERM U1254, CHU Nancy, Vandoeuvre-lès-Nancy, France
| | | | | | - Lionel Nace
- Urgences, CHRU de Nancy, Nancy, Lorraine, France
| | - Gérard Audibert
- Hôpital Central, Service d'Anesthésie-Réanimation, CHRU Nancy, Nancy, France
| | - Hamza Achit
- CIC-1433 Epidémiologie clinique, Centre Hospitalier Universitaire de Nancy, Vandoeuvre-lès-Nancy, France
| | - Vincent Costalat
- Neuroradiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Caroline Arquizan
- Neurology, Stroke Unit, CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Olivier Beaufils
- Urgences, CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Arturo Consoli
- Neuroradiology, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
- Neuroradiology, Hopital Foch, Suresnes, France
| | - Bertrand Lapergue
- Neurology, Stroke Unit, Hôpital Foch, Suresnes, Île-de-France, France
| | | | - Aymeric Rouchaud
- Interventional Neuroradiology, CHU Limoges, Limoges, Limousin, France
| | | | | | | | | | | | - Gaultier Marnat
- Neuroradiology, CHU de Bordeaux, Bordeaux, Aquitaine, France
| | - Igor Sibon
- Neurology, Stroke Unit, CHU Bordeaux, Bordeaux, France
| | - Xavier Combes
- Anesthesiology, CHU de Bordeaux, Bordeaux, Aquitaine, France
| | | | | | | | - Laurent Pierot
- Neuroradiology, CHU Reims, Reims, Champagne-Ardenne, France
| | - Solene Moulin
- Neurology, Stroke Unit, CHU Reims, Reims, Champagne-Ardenne, France
| | | | - Mikael Mazighi
- Interventional Neuroradiology, Fondation Rothschild, Paris, Île-de-France, France
| | - Raphael Blanc
- Interventional Neuroradiology, Fondation Rothschild, Paris, Île-de-France, France
| | - Candice Sabben
- Neurology, Stroke Unit, Fondation Rothschild, Paris, Île-de-France, France
| | - Eric Schluck
- Neurology, Stroke Unit, GHR Mulhouse Sud Alsace, Mulhouse, France
| | - Serge Bracard
- Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- INSERM U1254, CHU Nancy, Vandoeuvre-lès-Nancy, France
| | - René Anxionnat
- Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- INSERM U1254, CHU Nancy, Vandoeuvre-lès-Nancy, France
| | | | - Gabriela Hossu
- INSERM U1254, CHU Nancy, Vandoeuvre-lès-Nancy, France
- INSERM CIC-IT 1433, CHU Nancy, Vandœuvre-lès-Nancy, France
| | - Benjamin Gory
- Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- INSERM U1254, CHU Nancy, Vandoeuvre-lès-Nancy, France
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Acute ischemic stroke & emergency mechanical thrombectomy: The effect of type of anesthesia on early outcome. Clin Neurol Neurosurg 2021; 202:106494. [PMID: 33493885 DOI: 10.1016/j.clineuro.2021.106494] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Endovascular mechanical thrombectomy (EMT) is the standard of care for acute ischemic stroke (AIS) caused by proximal large vessel occlusions. There is conflicting evidence on outcome of patients undergoing EMT under procedural sedation (PS) or general anesthesia (GA). In this retrospective study we analyze the effect of GA and PS on the functional outcome of patients undergoing EMT. METHODS Patients who have been admitted at our institute AIS and were treated with EMT under GA or PS between January 2015 and September 2018 were included in the study. Primary end point was the proportion of patients with good functional outcome as defined by a modified Rankin score (mRS) 0-2 at discharge. RESULTS A total of 155 patients were analyzed in this study including 45 (29.03 %) patients who received 97 GA, 110 (70.9 %) PS and 31 of these received Dexmedetomidine/Remifentanil. The median (IQR) 98 mRS at discharge was 4.0 (1.0-4.0) in the GA group Vs 3.00, (1.00-4.00) in the PS group. Among the secondary outcomes the lowest MAP recorded was significantly less in GA group (64.56 100 ± 18.70) compared to PS group (70.86 ± 16.30); p = 0.03. The PS group had a lower odd of mRS 3-5 (after adjustment), however, this finding was statistically not significant (OR 0.52 [0.07-3.5] 102 p = 0.5). CONCLUSIONS Our retrospective analysis did not find any influence of GA compared to PS whenever this was delivered by target controlled infusion (TCI) of propofol or by remifentanil/dexmedetomidine (REX) on early functional outcome.
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New paradigm shift in perioperative medicine: General anaesthesia finally better than procedural sedation for anterior circulation stroke thrombectomy? Anaesth Crit Care Pain Med 2020; 38:585-587. [PMID: 31785703 DOI: 10.1016/j.accpm.2019.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/12/2019] [Indexed: 11/23/2022]
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