Choice of ANaesthesia for EndoVAScular treatment of acute ischaemic stroke at posterior circulation (CANVAS II): protocol for an exploratory randomised controlled study

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

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.

The Impact of Nursing Interventions on the Treatment Outcomes of Renal Cell Carcinoma with Postoperative Interleukin-2 and Recombinant Human Interferon

Objective

This study investigates the impact of nursing interventions on treatment outcomes and adverse reaction rates in renal cell carcinoma (RCC) patients treated postoperatively with Interleukin-2 and recombinant human Interferon.

Methods

In a retrospective analysis of 90 RCC patients, 43 received standard care (control group), while 47 received additional nursing interventions (intervention group), including psychological care, vital signs monitoring, dietary care, adverse reaction management, and post-discharge care. Patients with concurrent major diseases or other malignancies were excluded. Key assessments included clinical symptom improvement, treatment efficacy, and postoperative adverse reactions.

Results

Among the 90 participants, no significant demographic differences were found between the two groups. The intervention group showed significant improvements in fever resolution, leukocyte normalization, and shorter hospital stays. The overall treatment effectiveness was similar in both groups (90.7% in the intervention group vs 91.5% in the control group). However, the intervention group experienced significantly fewer postoperative adverse reactions, including fever, gastrointestinal symptoms, bone marrow suppression, and neurological abnormalities (6.3% vs 23.2%).

Conclusion

The study suggests that nursing interventions can improve treatment outcomes by reducing postoperative adverse reactions in RCC patients receiving postoperative Interleukin-2 and recombinant human Interferon. The overall effectiveness of treatment and care was comparable between the groups. Further extensive studies are needed to confirm these findings and fully understand the impact of nursing interventions on RCC patient outcomes.

Early Intubation in Endovascular Therapy for Basilar Artery Occlusion: A Post Hoc Analysis of the BASICS Trial

BACKGROUND

The optimal anesthetic management for endovascular therapy (EVT) in patients with posterior circulation stroke remains unclear. Our objective was to investigate the impact of early intubation in patients enrolled in the BASICS trial (Basilar Artery International Cooperation Study).

METHODS

BASICS was a multicenter, randomized, controlled trial that compared the efficacy of EVT compared with the best medical care alone in patients with basilar artery occlusion. In this post hoc analysis, early intubation within the first 24 hours of the estimated time of basilar artery occlusion was examined as an additional covariate using regression modeling. We estimated the adjusted relative risks (RRs) for favorable outcomes, defined as modified Rankin Scale scores of 0 to 3 at 90 days. An adjusted common odds ratio was estimated for a shift in the distribution of modified Rankin Scale scores at 90 days.

RESULTS

Of 300 patients in BASICS, 289 patients were eligible for analysis (151 in the EVT group and 138 in the best medical care group). compared with medical care alone, EVT was related to a higher risk of early intubation (RR, 1.29 [95% CI, 1.09-1.53]; P<0.01), and early intubation was negatively associated with favorable outcome (RR, 0.61 [95% CI, 0.45-0.84]; P=0.002). Whereas there was no overall treatment effect of EVT on favorable outcome (RR, 1.22 [95% CI, 0.95-1.55]; P=0.121), EVT was associated with favorable outcome (RR, 1.34 [95% CI, 1.05-1.71]; P=0.018) and a shift toward lower modified Rankin Scale scores (adjusted common odds ratio, 1.63 [95% CI, 1.04-2.57]; P=0.033) if adjusted for early intubation.

CONCLUSIONS

In this post hoc analysis of the neutral BASICS trial, early intubation was linked to unfavorable outcomes, which might mitigate a potential benefit from EVT by indirect effects due to an increased risk of early intubation. This relationship may be considered when assessing the efficacy of EVT in patients with basilar artery occlusion in future trials.

Anaesthetic and peri-operative management for thrombectomy procedures in stroke patients

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.

General Anesthesia vs Conscious Sedation for Endovascular Treatment in Patients With Posterior Circulation Acute Ischemic Stroke: An Exploratory Randomized Clinical Trial

Importance

No definitive conclusion can be made on the best choice of anesthesia for people with acute posterior circulation stroke during endovascular treatment. Only a few observational studies have focused on this topic in recent years, and they have differing conclusions.

Objective

To examine whether conscious sedation (CS) is a feasible alternative to general anesthesia (GA) during endovascular treatment in patients with acute posterior circulation stroke.

Design, Setting, and Participants

A randomized parallel-group exploratory trial with blinded end point evaluation (Choice of Anesthesia for Endovascular Treatment of Acute Ischemic Stroke [CANVAS II]) enrolled adult patients from March 2018 to June 2021 at 2 comprehensive care hospitals in China. Patients with acute posterior circulation stroke were enrolled, randomized, and monitored for 3 months. Of 210 patients admitted with acute ischemic posterior circulation stroke, 93 were recruited and 87 were included in the intention-to-treat (ITT) analysis after exclusions, 43 were assigned to GA and 44 to CS. All analyses were unadjusted or adjusted with the ITT principle.

Interventions

Participants were randomly assigned to CS or GA in a 1:1 ratio.

Main Outcomes and Measures

The primary end point was functional independence at 90 days evaluated with the modified Rankin Scale (mRS).

Results

A total of 87 participants were included in the ITT study (mean [SD] age, 62 [12] years; 16 [18.4%] female and 71 [81.6%] male). Of these, 43 were in the GA group and 44 in the CS group. The overall baseline median (IQR) National Institute of Health Stroke Scale (NIHSS) score was 15 (12-17). In the CS group, 13 people (29.5%) were ultimately transferred to GA. The CS group had a higher incidence of functional independence; however, no significant difference was found between the 2 groups (48.8% vs 54.5%; risk ratio, 0.89; 95% CI, 0.58-1.38; adjusted odds ratio [OR], 0.91; 95% CI, 0.37-2.22). However, GA performed better in successful reperfusion (mTICI 2b-3) under ITT analysis (95.3% vs 77.3%; adjusted OR, 5.86; 95% CI, 1.16-29.53).

Conclusion and Relevance

The findings in this study suggest that CS was not better than GA for the primary outcome of functional recovery and was perhaps worse for the secondary outcome of successful reperfusion.

Trial Registration

ClinicalTrials.gov Identifier: NCT03317535.

General anesthesia versus conscious sedation during endovascular treatment in posterior circulation large vessel occlusion: A systematic review and meta-analysis

Purpose:

The optimal anesthetic approach in the endovascular treatment (EVT) of patients with posterior circulation large vessel occlusion (PC-LVO) strokes is not clear. Little data has been published and no randomized clinical trials have been conducted so far. We aimed to perform an updated meta-analysis to compare clinical and procedural outcomes between conscious sedation (CS) and general anesthesia (GA).

Methods:

We reviewed the literature of the studies reporting CS and GA in patients with endovascularly-treated PC-LVO. The primary outcome was the functional outcome at 3 months measured using the modified Rankin Scale (mRS). A good functional outcome was defined as having a mRS 0–2. Secondary outcomes were mortality at 3 months, final successful recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) scale from 2b to 3) and complete recanalization (mTICI of 3) and times from stroke onset to EVT completion. Random-effects models were completed to pool the outcomes and the I2 value was calculated to assess heterogeneity.

Findings:

Eight studies with a total of 1351 patients were included. The pooled results reveal that CS use was associated with higher rates of good outcome (OR 2.41, 95% CI 1.58–3.64, I2 = 49.67%) and with lower mortality at 3 months (OR 0.48, 95% CI 0.28–0.82, I2 =57.11%). No significant differences were observed in the final reperfusion rates, procedural duration, and time from stroke onset to EVT completion.

Conclusion:

In this meta-analysis, GA was associated with significantly lower rates of functional independence at 3 months in patients with PC-LVO strokes.

General anesthesia or conscious sedation for endovascular therapy of basilar artery occlusions: ETIS registry results

BACKGROUND AND PURPOSE

Acute basilar artery occlusions (BAO) are associated with poor outcome despite modern endovascular treatment (EVT). The best anesthetic management during EVT is not known and may affect the procedure and clinical outcome. We compared the efficacy and safety of general anesthesia (GA) and conscious sedation/local anesthesia (CS/LA) in a large cohort of stroke patients with BAO treated with EVT in current clinical practice.

METHODS

Data from the ongoing prospective multicenter Endovascular Treatment In Ischemic Stroke Registry of consecutive acute BAO patients who had EVT indication from January 1st, 2015, to December 31st, 2021, were retrospectively analyzed. Two groups were compared: patients treated with CS/LA versus GA (both types of anesthesia being performed in the angiosuite). Good outcome was defined as modified Rankin Scale (mRS) score 0-3 at 90 days.

RESULTS

Among the 524 included patients, 266 had GA and 246 had CS/LA (67 LA). Fifty-three patients finally did not undergo EVT: 15 patients (5.9%) in the GA group and 38 patients (16.1%) in the CS/LA group (P < 0.001). After matching, two groups of 129 patients each were retained for primary analysis. The two groups were well balanced in terms of baseline characteristics. After adjustment, CS/LA compared to GA was not associated with good outcome (OR=0.90 [95%CI 0.46-1.77] P=0.769) or mortality (OR=0.75 [0.37-1.49] P=0.420) or modified thrombolysis in cerebral infarction score 2b-3 (OR=0.43 [0.16-1.16] P=0.098). On mixed ordinal logistic regression, the modality of anesthesia was not associated with any significant change in the overall distribution of the 90-day mRS (adjusted OR=1.08 [0.62-1.88] P=0.767).

CONCLUSIONS

Safety, outcome and quality of EVT under either CS/LA or GA for stroke due to acute BAO appear similar. Further randomized trials are warranted.

Type of anaesthesia for acute ischaemic stroke endovascular treatment

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.