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Taboada M, Estany-Gestal A, Fernández J, Barreiro L, Williams K, Rodríguez-Yáñez M, Otero P, Naveira A, Caruezo V, Veiras S, San Luis E, Dos Santos L, Diaz-Vieito M, Arias-Rivas S, Santamaría-Cadavid M, Rodríguez-Castro E, Vázquez F, Blanco M, Mosquera A, Castiñeiras JA, Muniategui I, Ferreiroa E, Cariñena A, Tubio A, Campaña O, Selas S, Aneiros F, Martínez A, Eiras M, Costa J, Prieto JM, Álvarez J. Effect of early vs. delayed extubation on functional outcome among patients with acute ischemic stroke treated with endovascular thrombectomy under general anesthesia: the prospective, randomized controlled EDESTROKE trial study protocol. Trials 2024; 25:357. [PMID: 38835061 PMCID: PMC11151624 DOI: 10.1186/s13063-024-08181-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/17/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Recent meta-analyses and randomized studies have shown that among patients with acute ischemic stroke undergoing endovascular thrombectomy, general anesthesia with mechanical ventilation is associated with better functional status compared to local anesthesia and sedation, and they recommend its use. But once the procedure is completed, when is the optimal moment for extubation? Currently, there are no guidelines recommending the optimal moment for extubation. Prolonged mechanical ventilation time could potentially be linked to increased complications such as pneumonia or disturbances in cerebral blood flow due to the vasodilatation produced by most anesthetic drugs. However, premature extubation in a patient who has suffered a stroke could led to complications such as agitation, disorientation, abolished reflexes, sudden fluctuations in blood pressure, alterations in cerebral blood flow, respiratory distress, bronchial aspiration, and the need for reintubation. We therefore designed a randomized study hypothesizing that early compared with delayed extubation is associated with a better functional outcome 3 months after endovascular thrombectomy treatment under general anesthesia for acute ischemic stroke. METHODS This investigator-initiated, single-center, prospective, parallel, evaluated blinded, superiority, randomized controlled trial will include 178 patients with a proximal occlusion of the anterior circulation treated with successful endovascular thrombectomy (TICI 2b-3) under general anesthesia. Patients will be randomly allocated to receive early (< 6 h) or delayed (6-12 h) extubation after the procedure. The primary outcome measure is functional independence (mRS of 0-2) at 90 days, measured with the modified Rankin Score (mRS), ranging from 0 (no symptoms) to 6 (death). DISCUSSION This will be the first trial to compare the effect of mechanical ventilation duration (early vs delayed extubation) after satisfactory endovascular thrombectomy for acute ischemic stroke under general anesthesia. TRIAL REGISTRATION The study protocol was approved April 11, 2023, by the by the Santiago-Lugo Research Ethics Committee (CEI-SL), number 2023/127, and was registered into the clinicaltrials.gov clinical trials registry with No. NCT05847309. Informed consent is required. Participant recruitment begins on April 18, 2023. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.
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Affiliation(s)
- Manuel Taboada
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain.
| | - Ana Estany-Gestal
- Research Methodology Unit, Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago, Spain
| | - Jorge Fernández
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Laura Barreiro
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Kora Williams
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | | | - Pablo Otero
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Alberto Naveira
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Valentín Caruezo
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Sonia Veiras
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Eva San Luis
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Laura Dos Santos
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - María Diaz-Vieito
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Susana Arias-Rivas
- Department of Neurology, University Clinical Hospital of Santiago, Santiago, Spain
| | | | | | - Fernando Vázquez
- Department of Neuroradiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Miguel Blanco
- Department of Neuroradiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Antonio Mosquera
- Department of Neuroradiology, University Clinical Hospital of Santiago, Santiago, Spain
| | | | - Ignacio Muniategui
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Esteban Ferreiroa
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Agustín Cariñena
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Ana Tubio
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Olga Campaña
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Salomé Selas
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Francisco Aneiros
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Adrián Martínez
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - María Eiras
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Jose Costa
- Department of Neuroradiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Jose María Prieto
- Department of Neurology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Julián Álvarez
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
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Arnalich-Montiel A, Burgos-Santamaría A, Pazó-Sayós L, Quintana-Villamandos B. Comprehensive Management of Stroke: From Mechanisms to Therapeutic Approaches. Int J Mol Sci 2024; 25:5252. [PMID: 38791292 PMCID: PMC11120719 DOI: 10.3390/ijms25105252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/29/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Acute ischemic stroke (AIS) is a challenging disease, which needs urgent comprehensive management. Endovascular thrombectomy (EVT), alone or combined with iv thrombolysis, is currently the most effective therapy for patients with acute ischemic stroke (AIS). However, only a limited number of patients are eligible for this time-sensitive treatment. Even though there is still significant room for improvement in the management of this group of patients, up until now there have been no alternative therapies approved for use in clinical practice. However, there is still hope, as clinical research with novel emerging therapies is now generating promising results. These drugs happen to stop or palliate some of the underlying molecular mechanisms involved in cerebral ischemia and secondary brain damage. The aim of this review is to provide a deep understanding of these mechanisms and the pathogenesis of AIS. Later, we will discuss the potential therapies that have already demonstrated, in preclinical or clinical studies, to improve the outcomes of patients with AIS.
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Affiliation(s)
- Ana Arnalich-Montiel
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
- Department of Pharmacology, College of Medicine, Complutense University, 28040 Madrid, Spain
| | - Alba Burgos-Santamaría
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
| | - Laia Pazó-Sayós
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
| | - Begoña Quintana-Villamandos
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
- Department of Pharmacology, College of Medicine, Complutense University, 28040 Madrid, Spain
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3
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Valente I, Alexandre AM, Colò F, Brunetti V, Frisullo G, Camilli A, Falcou A, Scarcia L, Gigli R, Scala I, Rizzo PA, Abruzzese S, Milonia L, Piano M, Macera A, Ruggiero M, Da Ros V, Bellini L, Lazzarotti GA, Cosottini M, Caragliano AA, Vinci SL, Gabrieli JD, Causin F, Panni P, Roveri L, Limbucci N, Arba F, Renieri L, Ferretti S, Pileggi M, Bianco G, Romano DG, Frauenfelder G, Semeraro V, Ganimede MP, Lozupone E, Fasano A, Lafe E, Cavallini AM, Mazzacane F, Russo R, Bergui M, Broccolini A, Pedicelli A. Effect of General Anesthesia Versus Conscious Sedation/Local Anesthesia on the Outcome of Patients with Minor Stroke and Isolated M2 Occlusion Undergoing Immediate Thrombectomy: A Retrospective Multicenter Matched Analysis. World Neurosurg 2024; 183:e432-e439. [PMID: 38154680 DOI: 10.1016/j.wneu.2023.12.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND This study investigates the impact of general anesthesia (GA) versus conscious sedation/local anesthesia (CS/LA) on the outcome of patients with minor stroke and isolated M2 occlusion undergoing immediate mechanical thrombectomy (iMT). METHODS The databases of 16 comprehensive stroke centers were retrospectively screened for consecutive patients with isolated M2 occlusion and a baseline National Institutes of Health Stroke Scale score ≤5 who received iMT. Propensity score matching was used to estimate the effect of GA versus CS/LA on clinical outcomes and procedure-related adverse events. The primary outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-1. Secondary outcome measures were a 90-day mRS score of 0-2 and all-cause mortality, successful reperfusion, procedural-related symptomatic subarachnoid hemorrhage, intraprocedural dissections, and new territory embolism. RESULTS Of the 172 patients who were selected, 55 received GA and 117 CS/LA. After propensity score matching, 47 pairs of patients were available for analysis. We found no significant differences in clinical outcome, rates of efficient reperfusion, and procedural-related complications between patients receiving GA or LA/CS (mRS score 0-1, P = 0.815; mRS score 0-2, P = 0.401; all-cause mortality, P = 0.408; modified Treatment in Cerebral Infarction score 2b-3, P = 0.374; symptomatic subarachnoid hemorrhage, P = 0.082; intraprocedural dissection, P = 0.408; new territory embolism, P = 0.462). CONCLUSIONS In patients with minor stroke and isolated M2 occlusion undergoing iMT, the type of anesthesia does not affect clinical outcome or the rate of procedural-related complications. Our results agree with recent data showing no benefit of one specific anesthesiologic procedure over the other and confirm their generalizability also to patients with minor baseline symptoms.
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Affiliation(s)
- Iacopo Valente
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea M Alexandre
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Colò
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Valerio Brunetti
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Frisullo
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Arianna Camilli
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Anne Falcou
- Stroke Unit, University Hospital Policlinico Umberto I, Rome, Italy
| | - Luca Scarcia
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | - Riccardo Gigli
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Irene Scala
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Pier A Rizzo
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Serena Abruzzese
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Luca Milonia
- Interventional Neuroradiology Unit, University Hospital Policlinico Umberto I, Rome, Italy
| | - Mariangela Piano
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Antonio Macera
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Valerio Da Ros
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Rome, Italy
| | - Luigi Bellini
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Rome, Italy
| | - Guido A Lazzarotti
- Neuroradiology Unit, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | - Mirco Cosottini
- Neuroradiology Unit, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | | | - Sergio L Vinci
- Neuroradiology Unit, AOU Policlinico G. Martino, Messina, Italy
| | - Joseph D Gabrieli
- Neuroradiology Unit, Policlinico Universitario di Padova, Padua, Italy
| | - Francesco Causin
- Neuroradiology Unit, Policlinico Universitario di Padova, Padua, Italy
| | - Pietro Panni
- Interventional Neuroradiology Unit and Neurology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - Luisa Roveri
- Neurology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - Nicola Limbucci
- Interventional Neurovascular Unit, Stroke Unit, A.O.U. Careggi, Firenze, Italy
| | | | - Leonardo Renieri
- Interventional Neurovascular Unit, Stroke Unit, A.O.U. Careggi, Firenze, Italy
| | - Simone Ferretti
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Marco Pileggi
- Neuroradiology Unit and Stroke Center, Neurocenter of Southern Switzerland-EOC, Lugano, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurocenter of Southern Switzerland-EOC, Lugano, Switzerland
| | - Daniele G Romano
- Neuroradiology Unit, AOU S Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Giulia Frauenfelder
- Neuroradiology Unit, AOU S Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Vittorio Semeraro
- Interventional Radiology Unit and Neuroradiology Unit, "SS Annunziata" Hospital, Taranto, Italy
| | | | - Emilio Lozupone
- Neuroradiology Unit and Neurology Unit, Vito Fazzi Hospital, Lecce, Italy
| | | | - Elvis Lafe
- Neuroradiology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna M Cavallini
- Cerebrovascular Diseases Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | | | - Riccardo Russo
- Neuroradiology Unit, Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | - Mauro Bergui
- Neuroradiology Unit, Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | - Aldobrando Broccolini
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy; Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Alessandro Pedicelli
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
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4
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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. Anesthetic management for large vessel occlusion acute ischemic stroke with tandem lesions. J Neurointerv Surg 2024:jnis-2023-021360. [PMID: 38429099 DOI: 10.1136/jnis-2023-021360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/13/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Mudassir Farooqui
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Afshin A Divani
- Neurology, University of New Mexico Health System, Albuquerque, New Mexico, USA
| | | | - Marc Ribo
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
- Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Nils H Petersen
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael G Abraham
- Neurology and Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Amer Malik
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Health Care, Camden, New Jersey, USA
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sunil A Sheth
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Guillermo Linares
- Neurology, School of Medicine Saint Louis University, Saint Louis, Missouri, USA
| | - Nazli Janjua
- Neurology, Pomona Valley Hospital Medical Center, Pomona, California, USA
| | - Darko Quispe-Orozco
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Wondwossen G Tekle
- Department of Neurology, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Sara Y Sabbagh
- Neurology, University of New Mexico Health System, Albuquerque, New Mexico, USA
| | - Syed F Zaidi
- Neurology, University of Toledo Health Science Campus, Toledo, Ohio, USA
| | | | - Ayush Prasad
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Abid Qureshi
- Neurology and Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | | | | | | | - Weston Gordon
- Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Aaron Rodriguez-Calienes
- The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Cientifica del Sur Facultad de Ciencias de la Salud, Lima, Peru
| | - Juan Vivanco-Suarez
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Dileep R Yavagal
- Neurology and Neurosurgery, University of Miami, Miami, Florida, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Santiago Ortega-Gutierrez
- Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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5
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Meyer L, Stracke CP, Broocks G, Wallocha M, Elsharkawy M, Sporns PB, Piechowiak EI, Kaesmacher J, Maegerlein C, Hernandez Petzsche MR, Zimmermann H, Naziri W, Abdullayev N, Kabbasch C, Behme D, Thormann M, Maus V, Fischer S, Möhlenbruch MA, Weyland CS, Langner S, Ernst M, Jamous A, Meila D, Miszczuk M, Siebert E, Lowens S, Krause LU, Yeo LL, Tan BYQ, Gopinathan A, Gory B, Galvan Fernandez J, Schüller Arteaga M, Navia P, Raz E, Shapiro M, Arnberg F, Zeleňák K, Martínez-Galdámez M, Alexandrou M, Kastrup A, Papanagiotou P, Dorn F, Kemmling A, Psychogios MN, Andersson T, Chapot R, Fiehler J, Hanning U. Effect of anesthetic strategies on distal stroke thrombectomy in the anterior and posterior cerebral artery. J Neurointerv Surg 2024; 16:230-236. [PMID: 37142393 DOI: 10.1136/jnis-2023-020210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/14/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Numerous questions regarding procedural details of distal stroke thrombectomy remain unanswered. This study assesses the effect of anesthetic strategies on procedural, clinical and safety outcomes following thrombectomy for distal medium vessel occlusions (DMVOs). METHODS Patients with isolated DMVO stroke from the TOPMOST registry were analyzed with regard to anesthetic strategies (ie, conscious sedation (CS), local (LA) or general anesthesia (GA)). Occlusions were in the P2/P3 or A2-A4 segments of the posterior and anterior cerebral arteries (PCA and ACA), respectively. The primary endpoint was the rate of complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3) and the secondary endpoint was the rate of modified Rankin Scale score 0-1. Safety endpoints were the occurrence of symptomatic intracranial hemorrhage and mortality. RESULTS Overall, 233 patients were included. The median age was 75 years (range 64-82), 50.6% (n=118) were female, and the baseline National Institutes of Health Stroke Scale score was 8 (IQR 4-12). DMVOs were in the PCA in 59.7% (n=139) and in the ACA in 40.3% (n=94). Thrombectomy was performed under LA±CS (51.1%, n=119) and GA (48.9%, n=114). Complete reperfusion was reached in 73.9% (n=88) and 71.9% (n=82) in the LA±CS and GA groups, respectively (P=0.729). In subgroup analysis, thrombectomy for ACA DMVO favored GA over LA±CS (aOR 3.07, 95% CI 1.24 to 7.57, P=0.015). Rates of secondary and safety outcomes were similar in the LA±CS and GA groups. CONCLUSION LA±CS compared with GA resulted in similar reperfusion rates after thrombectomy for DMVO stroke of the ACA and PCA. GA may facilitate achieving complete reperfusion in DMVO stroke of the ACA. Safety and functional long-term outcomes were comparable in both groups.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Paul Stracke
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marta Wallocha
- Department of Endovascular Therapy, Alfred-Krupp Hospital, Essen, Germany
| | - Mohamed Elsharkawy
- Department of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Peter B Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Eike I Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Moritz Roman Hernandez Petzsche
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Hanna Zimmermann
- Institute of Neuroradiology, University Hospitals, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Weis Naziri
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
- Department of Neuroradiology, University Hospital Luebeck, Luebeck, Germany
| | - Nuran Abdullayev
- Department of Neuroradiology, University of Cologne, Cologne, Germany
| | | | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Maximilian Thormann
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Volker Maus
- Department of Diagnostic Radiology and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| | - Sebastian Fischer
- Department of Diagnostic Radiology and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Soenke Langner
- Institute for Diagnostic and Interventional Radiology, Pediatric and Neuroradiology, University Hospital Rostock, Rostock, Germany
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Goettingen, Goettingen, Germany
| | - Ala Jamous
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Goettingen, Goettingen, Germany
| | - Dan Meila
- Department of Interventional Neuroradiology, Johanna-Étienne-Hospital, Neuss, Germany
| | - Milena Miszczuk
- Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Lowens
- Department of Radiology, Klinikum Osnabrück, Osnabrück, Germany
| | - Lars Udo Krause
- Department of Neurology, Klinikum Osnabrück, Osnabrück, Germany
| | - Leonard Ll Yeo
- Division of Neurology, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anil Gopinathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Interventional Radiology, Department of Diagnostic imaging, National University Health System, Singapore
| | - Benjamin Gory
- Université de Lorraine, CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, F-54000 Nancy, France, Université de Lorraine, IADI, INSERM U1254, F-54000, Nancy, France
| | - Jorge Galvan Fernandez
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Miguel Schüller Arteaga
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Pedro Navia
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Eytan Raz
- Department of Radiology, New York Langone Medical Center, New York, New York, USA
| | - Maksim Shapiro
- Department of Radiology, New York Langone Medical Center, New York, New York, USA
| | - Fabian Arnberg
- Departments of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
| | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Mario Martínez-Galdámez
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Maria Alexandrou
- Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany
| | - Panagiotis Papanagiotou
- Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
- Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - André Kemmling
- Department of Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Marios-Nikos Psychogios
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Tommy Andersson
- Departments of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - René Chapot
- Department of Endovascular Therapy, Alfred-Krupp Hospital, Essen, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Barlinn K, Langezaal LCM, Dippel DWJ, van Zwam WH, Roessler M, Roos YBWEM, Emmer BJ, van Oostenbrugge RJ, Gerber JC, Yoo AJ, Pontes-Neto OM, Mazighi M, Audebert HJ, Michel P, Schonewille WJ, Puetz V. Early Intubation in Endovascular Therapy for Basilar Artery Occlusion: A Post Hoc Analysis of the BASICS Trial. Stroke 2023; 54:2745-2754. [PMID: 37871243 DOI: 10.1161/strokeaha.123.043669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/30/2023] [Indexed: 10/25/2023]
Abstract
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.
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Affiliation(s)
- Kristian Barlinn
- Department of Neurology (K.B., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (K.B., J.C.G., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | | | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands (D.W.J.D.)
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine (W.H.v.Z.), School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
| | - Martin Roessler
- BARMER Institute for Health Care System Research (bifg), Berlin, Germany (M.R.)
| | - Yvo B W E M Roos
- Department of Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, the Netherlands
| | - Bart J Emmer
- Department of Radiology (B.J.E.), Amsterdam University Medical Center, the Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology (R.J.v.O.), School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
| | - Johannes C Gerber
- Dresden Neurovascular Center (K.B., J.C.G., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Institute of Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (J.C.G.)
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth (A.J.Y.)
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Brazil (O.M.P.-N.)
| | - Mikael Mazighi
- Departments of Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Foundation Rothschild Hospital, FHU Neurovasc, INSERM 1144, Paris Cite University, France (M.M.)
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research, Charité Universitätsmedizin Berlin, Germany (H.J.A.)
| | - Patrik Michel
- The Stroke Center, Neurology Service, Lausanne University Hospital, Switzerland (P.M.)
| | - Wouter J Schonewille
- Department of Neurology, St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.)
| | - Volker Puetz
- Department of Neurology (K.B., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (K.B., J.C.G., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
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7
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Zhang M, Xing P, Tang J, Shi L, Yang P, Zhang Y, Zhang L, Peng Y, Liu S, Zhang L, Fu J, Liu J. Predictors and outcome of early neurological deterioration after endovascular thrombectomy: a secondary analysis of the DIRECT-MT trial. J Neurointerv Surg 2023; 15:e9-e16. [PMID: 35688618 DOI: 10.1136/neurintsurg-2022-018976] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/19/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is uncertainty regarding the predictors of early neurological deterioration (END) after endovascular thrombectomy in patients with acute ischemic stroke (AIS). Limited studies have focused on the effect of END on functional outcome. Our aim was to determine the predictors of END after endovascular thrombectomy in AIS and its effect on functional outcome at 90 days. METHODS This is a secondary analysis of the DIRECT-MT trial. Patients who failed to complete endovascular thrombectomy were additionally excluded. END was defined as ≥4-point increase in National Institutes of Health Stroke Scale score between admission and 24 hours after endovascular thrombectomy. Multivariable logistic regression was used to identify predictors for END and its effect on the modified Rankin Scale (mRS) score at 90 days. RESULTS Of 591 patients enrolled, 111 (18.8%) had postoperative END, which was associated with higher ordinal mRS score at 90 days (adjusted common OR (aOR) 6.968, 95% CI 4.444 to 10.926). Non-modifiable factors included baseline Alberta Stroke Program Early CT Score (aOR 0.883, 95% CI 0.790 to 0.987), systolic blood pressure (aOR 1.017, 95% CI 1.006 to 1.028), glucose level (aOR 1.178, 95% CI 1.090 to 1.273), collateral status (aOR 0.238, 95% CI 0.093 to 0.608), occlusion site (aOR 0.496, 95% CI 0.290 to 0.851) and the presence of an anterior communicating artery (aOR 0.323, 95% CI 0.148 to 0.707). Admission-to-groin puncture time (aOR 1.010, 95% CI 1.003 to 1.017), general anesthesia (aOR 2.299, 95% CI 1.193 to 4.444), number of passes (aOR 1.561, 95% CI 1.243 to 1.961) and contrast extravasation (aOR 6.096, 95% CI 1.543 to 24.088) were modifiable predictors for END. CONCLUSIONS Postoperative END is associated with adverse functional outcome. Several non-modifiable and modifiable factors can predict END and support future treatment decision-making to improve the potential utility of endovascular thrombectomy. TRIAL REGISTRATION NUMBER DIRECT-MT ClinicalTrials.gov NCT03469206.
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Affiliation(s)
- Miaoyi Zhang
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Changhai Hospital, Shanghai, China
| | - Jie Tang
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Langfeng Shi
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital, Shanghai, China
| | - Ya Peng
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, China
| | - Sheng Liu
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Liyong Zhang
- Department of Vascular Neurosurgery, Liaocheng Brain Hospital, Liaocheng, China
| | - Jianhui Fu
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Shanghai, China
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8
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Tao C, Yuan G, Xu P, Wang H, Zhou P, Yi T, Li K, Cui T, Gao J, Li R, Sun J, Zhang C, Wang L, Liu T, Song J, Yin Y, Nguyen TN, Li Q, Hu W. Anesthetic Management and Outcomes of Endovascular Treatment of Basilar Artery Occlusion: Results From the ATTENTION Registry. J Stroke 2023; 25:399-408. [PMID: 37607695 PMCID: PMC10574300 DOI: 10.5853/jos.2023.00318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/11/2023] [Accepted: 06/07/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND AND PURPOSE To examine the clinical and safety outcomes after endovascular treatment (EVT) for acute basilar artery occlusion (BAO) with different anesthetic modalities. METHODS This was a retrospective analysis using data from the Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION) registry. Patients were divided into two groups defined by anesthetic modality performed during EVT: general anesthesia (GA) or non-general anesthesia (non-GA). The association between anesthetic management and clinical outcomes was evaluated in a propensity score matched (PSM) cohort and an inverse probability of treatment weighting (IPTW) cohort to adjust for imbalances between the two groups. RESULTS Our analytic sample included 1,672 patients from 48 centers. The anesthetic modality was GA in 769 (46.0%) and non-GA in 903 (54.0%) patients. In our primary analysis with the PSM-based cohort, non-GA was comparable to GA concerning the primary outcome (adjusted common odds ratio [acOR], 1.01; 95% confidence interval [CI], 0.82 to 1.25; P=0.91). Mortality at 90 days was 38.4% in the GA group and 35.8% in the non-GA group (adjusted risk ratio, 0.95; 95% CI, 0.83 to 1.08; P=0.44). In our secondary analysis with the IPTW-based cohort, the anesthetic modality was significantly associated with the distribution of modified Rankin Scale at 90 days (acOR: 1.45 [95% CI: 1.20 to 1.75]). CONCLUSION In this nationally-representative observational study, acute ischemic stroke patients due to BAO undergoing EVT without GA had similar clinical and safety outcomes compared with patients treated with GA. These findings provide the basis for large-scale randomized controlled trials to test whether anesthetic management provides meaningful clinical effects for patients undergoing EVT.
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Affiliation(s)
- Chunrong Tao
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Pengfei Xu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Hao Wang
- Department of Neurology, Linyi People’s Hospital, Linyi, China
| | - Peiyang Zhou
- Department of Neurology, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Kai Li
- Department of Neurology, Heze Municipal Hospital, Heze, Shandong, China
| | - Tao Cui
- Department of Neurology, Taihe County People’s Hospital, Fuyang, China
| | - Jun Gao
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Rui Li
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Jun Sun
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Chao Zhang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Li Wang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Tianlong Liu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Jianlong Song
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yamei Yin
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Qing Li
- Department of Laboratory Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Core Facility Center, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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9
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Li Z, Ma H, Li B, Zhang L, Zhang Y, Xing P, Zhang Y, Zhang X, Zhou Y, Huang Q, Li Q, Zuo Q, Ye X, Liu J, Qureshi AI, Chen W, Yang P. Impact of anesthesia modalities on functional outcome of mechanical thrombectomy in patients with acute ischemic stroke: a subgroup analysis of DIRECT-MT trial. Eur J Med Res 2023; 28:228. [PMID: 37430361 DOI: 10.1186/s40001-023-01171-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 06/14/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND This subgroup analysis of Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals Multicenter Randomized Clinical Trial (DIRECT-MT) aimed to investigate the influence of anesthesia modalities on the outcomes of endovascular treatment. METHODS Patients were divided into two groups by receiving general anesthesia (GA) or non-general anesthesia (non-GA). The primary outcome was assessed by the between-group difference in the distribution of the modified Rankin Scale (mRS) at 90 days, estimated using the adjusted common odds ratio (acOR) by multivariable ordinal regression. Differences in workflow efficiency, procedural complication, and safety outcomes were analyzed. RESULTS Totally 636 patients were enrolled (207 for GA and 429 for non-GA groups). There was no significant shift in the mRS distribution at 90 days between the two groups (acOR, 1.093). The median time from randomization to reperfusion was significantly longer in GA group (116 vs. 93 min, P < 0.0001). Patients in non-GA group were associated with a significantly lower NIHSS score at early stages (24 h, 11 vs 15; 5-7 days or discharge, 6.5 vs 10). The rate of severe manipulation-related complication did not differ significantly between GA and non-GA groups (0.97% vs 3.26%; P = 0.08). There are no differences in the rate of mortality and intracranial hemorrhage. CONCLUSIONS In the subgroup analysis of DIRECT-MT, we found no significant difference in the functional outcome at 90 days between general anesthesia and non-general anesthesia, despite the workflow time being significantly delayed for patients with general anesthesia. Clinical trail registration clinicaltrials.gov Identifier: NCT03469206.
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Affiliation(s)
- Zifu Li
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Hongyu Ma
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Binben Li
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoxi Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yu Zhou
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiang Li
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiao Zuo
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaofei Ye
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Wenhuo Chen
- Department of Neurology, Municipal Hospital of Zhangzhou, Zhangzhou, Fujian Province, China.
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China.
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10
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Campbell D, Butler E, Campbell RB, Ho J, Barber PA. General Anesthesia Compared With Non-GA in Endovascular Thrombectomy for Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Neurology 2023; 100:e1655-e1663. [PMID: 36797071 PMCID: PMC10115505 DOI: 10.1212/wnl.0000000000207066] [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: 06/20/2022] [Accepted: 01/03/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular thrombectomy (EVT) for large vessel occlusion ischemic stroke is either performed under general anesthesia (GA) or with non-GA techniques such as conscious sedation or local anesthesia alone. Previous small meta-analyses have demonstrated superior recanalization rates and improved functional recovery with GA when compared with non-GA techniques. The publication of further randomized controlled trials (RCTs) could provide updated guidance when choosing between GA and non-GA techniques. METHODS A systematic search for trials in which stroke EVT patients were randomized to GA or non-GA was performed in Medline, Embase, and the Cochrane Central Register of Controlled Trials. A systematic review and meta-analysis using a random-effects model was performed. RESULTS Seven RCTs were included in the systematic review and meta-analysis. These trials included a total of 980 participants (GA, N = 487; non-GA, N = 493). GA improves recanalization by 9.0% (GA 84.6% vs non-GA 75.6%; odds ratio [OR] 1.75, 95% CI 1.26-2.42, p = 0.0009), and the proportion of patients with functional recovery improves by 8.4% (GA 44.6% vs non-GA 36.2%; OR 1.43, 95% CI 1.04-1.98, p = 0.03). There was no difference in hemorrhagic complications or 3-month mortality. DISCUSSION In patients with ischemic stroke treated with EVT, GA is associated with higher recanalization rates and improved functional recovery at 3 months compared with non-GA techniques. Conversion to GA and subsequent intention-to-treat analysis will underestimate the true therapeutic benefit. GA is established as effective in improving recanalization rates in EVT (7 Class 1 studies) with a high Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) certainty rating. GA is established as effective in improving functional recovery at 3 months in EVT (5 Class 1 studies) with a moderate GRADE certainty rating. Stroke services need to develop pathways to incorporate GA as the first choice for most EVT procedures in acute ischemic stroke with a level A recommendation for recanalization and level B recommendation for functional recovery.
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Affiliation(s)
- Douglas Campbell
- From the Auckland City Hospital (D.C., E.B.); University of Otago (R.B.C.), Dunedin; and University of Auckland (J.H., P.A.B.), New Zealand.
| | - Elise Butler
- From the Auckland City Hospital (D.C., E.B.); University of Otago (R.B.C.), Dunedin; and University of Auckland (J.H., P.A.B.), New Zealand
| | - Ruby Blythe Campbell
- From the Auckland City Hospital (D.C., E.B.); University of Otago (R.B.C.), Dunedin; and University of Auckland (J.H., P.A.B.), New Zealand.
| | - Jess Ho
- From the Auckland City Hospital (D.C., E.B.); University of Otago (R.B.C.), Dunedin; and University of Auckland (J.H., P.A.B.), New Zealand
| | - P Alan Barber
- From the Auckland City Hospital (D.C., E.B.); University of Otago (R.B.C.), Dunedin; and University of Auckland (J.H., P.A.B.), New Zealand
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11
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Lu Y, Xu P, Wang J, Xiao L, Zhang P, Duan Z, Liu D, Liu C, Wang D, Wang D, Zhang C, Yao T, Sun W, Cheng Z, Li M. General anesthesia vs. non-general anesthesia for vertebrobasilar stroke endovascular therapy. Front Neurol 2023; 14:1104487. [PMID: 36816562 PMCID: PMC9932259 DOI: 10.3389/fneur.2023.1104487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
Background The optimal type of anesthesia for acute vertebrobasilar artery occlusion (VBAO) remains controversial. We aimed to assess the influence of anesthetic management on the outcomes in VBAO patients received endovascular treatment (EVT). Methods Patients underwent EVT for acute VBAO at 21 stroke centers in China were retrospectively enrolled and compared between the general anesthesia (GA) group and non-GA group. The primary outcome was the favorable outcome, defined as a modified Rankin Scale (mRS) score 0-3 at 90 days. Secondary outcomes included functional independence (90-day mRS score 0-2), and the rate of successful reperfusion. The safety outcomes included all-cause mortality at 90 days, the occurrence of any procedural complication, and the rate of symptomatic intracranial hemorrhage (sICH). In addition, we performed analyses of the outcomes in subgroups that were defined by Glasgow Coma Scale (GCS) score (≤8 or >8). Results In the propensity score matched cohort, there were no difference in the primary outcome, secondary outcomes and safety outcomes between the two groups. Among patients with a GCS score of 8 or less, the proportion of successful reperfusion was significantly higher in the GA group than the non-GA group (aOR, 3.57, 95% CI 1.06-12.50, p = 0.04). In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar results were found. Conclusions Patients placed under GA during EVT for VBAO appear to be as effective and safe as non-GA. Furthermore, GA might yield better successful reperfusion for worse presenting GCS score (≤8). Registration URL: http://www.chictr.org.cn/; Unique identifier: ChiCTR2000033211.
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Affiliation(s)
- Yanan Lu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Pengfei Xu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Jinjing Wang
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Lulu Xiao
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Pan Zhang
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Zuowei Duan
- Department of Neurology, Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Dezhi Liu
- Department of Neurology, Shuguang Hospital Affiliated With Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chaolai Liu
- Department of Neurology, The First People's Hospital of Jining, Jining, Shandong, China
| | - Delong Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Di Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Chao Zhang
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Tao Yao
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Wen Sun
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Zhaozhao Cheng
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China,*Correspondence: Zhaozhao Cheng ✉
| | - Min Li
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China,Min Li ✉
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Sarraj A, Albers GW, Mitchell PJ, Hassan AE, Abraham MG, Blackburn S, Sharma G, Yassi N, Kleinig TJ, Shah DG, Wu TY, Hussain MS, Tekle WG, Gutierrez SO, Aghaebrahim AN, Haussen DC, Toth G, Pujara D, Budzik RF, Hicks W, Vora N, Edgell RC, Slavin S, Lechtenberg CG, Maali L, Qureshi A, Rosterman L, Abdulrazzak MA, AlMaghrabi T, Shaker F, Mir O, Arora A, Martin-Schild S, Sitton CW, Churilov L, Gupta R, Lansberg MG, Nogueira RG, Grotta JC, Donnan GA, Davis SM, Campbell BCV. Thrombectomy Outcomes With General vs Nongeneral Anesthesia: A Pooled Patient-Level Analysis From the EXTEND-IA Trials and SELECT Study. Neurology 2023; 100:e336-e347. [PMID: 36289001 PMCID: PMC9869759 DOI: 10.1212/wnl.0000000000201384] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 08/24/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The effect of anesthesia choice on endovascular thrombectomy (EVT) outcomes is unclear. Collateral status on perfusion imaging may help identify the optimal anesthesia choice. METHODS In a pooled patient-level analysis of EXTEND-IA, EXTEND-IA TNK, EXTEND-IA TNK part II, and SELECT, EVT functional outcomes (modified Rankin Scale score distribution) were compared between general anesthesia (GA) vs non-GA in a propensity-matched sample. Furthermore, we evaluated the association of collateral flow on perfusion imaging, assessed by hypoperfusion intensity ratio (HIR) - Tmax > 10 seconds/Tmax > 6 seconds (good collaterals - HIR < 0.4, poor collaterals - HIR ≥ 0.4) on the association between anesthesia type and EVT outcomes. RESULTS Of 725 treated with EVT, 299 (41%) received GA and 426 (59%) non-GA. The baseline characteristics differed in presentation National Institutes of Health Stroke Scale score (median [interquartile range] GA: 18 [13-22], non-GA: 16 [11-20], p < 0.001) and ischemic core volume (GA: 15.0 mL [3.2-38.0] vs non-GA: 9.0 mL [0.0-31.0], p < 0.001). In addition, GA was associated with longer last known well to arterial access (203 minutes [157-267] vs 186 minutes [138-252], p = 0.002), but similar procedural time (35.5 minutes [23-59] vs 34 minutes [22-54], p = 0.51). Of 182 matched pairs using propensity scores, baseline characteristics were similar. In the propensity score-matched pairs, GA was independently associated with worse functional outcomes (adjusted common odds ratio [adj. cOR]: 0.64, 95% CI: 0.44-0.93, p = 0.021) and higher neurologic worsening (GA: 14.9% vs non-GA: 8.9%, aOR: 2.10, 95% CI: 1.02-4.33, p = 0.045). Patients with poor collaterals had worse functional outcomes with GA (adj. cOR: 0.47, 95% CI: 0.29-0.76, p = 0.002), whereas no difference was observed in those with good collaterals (adj. cOR: 0.93, 95% CI: 0.50-1.74, p = 0.82), p interaction: 0.07. No difference was observed in infarct growth overall and in patients with good collaterals, whereas patients with poor collaterals demonstrated larger infarct growth with GA with a significant interaction between collaterals and anesthesia type on infarct growth rate (p interaction: 0.020). DISCUSSION GA was associated with worse functional outcomes after EVT, particularly in patients with poor collaterals in a propensity score-matched analysis from a pooled patient-level cohort from 3 randomized trials and 1 prospective cohort study. The confounding by indication may persist despite the doubly robust nature of the analysis. These findings have implications for randomized trials of GA vs non-GA and may be of utility for clinicians when making anesthesia type choice. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that use of GA is associated with worse functional outcome in patients undergoing EVT. TRIAL REGISTRATION INFORMATION EXTEND-IA: ClinicalTrials.gov (NCT01492725); EXTEND-IA TNK: ClinicalTrials.gov (NCT02388061); EXTEND-IA TNK part II: ClinicalTrials.gov (NCT03340493); and SELECT: ClinicalTrials.gov (NCT02446587).
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Affiliation(s)
- Amrou Sarraj
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX.
| | - Gregory W Albers
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Peter J Mitchell
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Ameer E Hassan
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Michael G Abraham
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Spiros Blackburn
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Gagan Sharma
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Nawaf Yassi
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Timothy J Kleinig
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Darshan G Shah
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Teddy Y Wu
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Muhammad Shazam Hussain
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Wondwoseen G Tekle
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Santiago Ortega Gutierrez
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Amin Nima Aghaebrahim
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Diogo C Haussen
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Gabor Toth
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Deep Pujara
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Ronald F Budzik
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - William Hicks
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Nirav Vora
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Randall C Edgell
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Sabreena Slavin
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Colleen G Lechtenberg
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Laith Maali
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Abid Qureshi
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Lee Rosterman
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Mohammad Ammar Abdulrazzak
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Tareq AlMaghrabi
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Faris Shaker
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Osman Mir
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Ashish Arora
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Sheryl Martin-Schild
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Clark W Sitton
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Leonid Churilov
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Rishi Gupta
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Maarten G Lansberg
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Raul G Nogueira
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - James C Grotta
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Geoffrey Alan Donnan
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Stephen M Davis
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
| | - Bruce C V Campbell
- From the Case Western Reserve University (A.S.), Neurology; University Hospitals Cleveland Medical Center (A.S., D.P.), Neurology, OH; Stanford University (G.W.A., M.G.L.), Neurology, CA; The Royal Melbourne Hospital - University of Melbourne (P.J.M.), Radiology, Parkville, Victoria, Australia; University of Texas Rio Grande Valley - Valley Baptist Medical Center (A.E.H., W.G.T.), Harlingen; University of Kansas Medical Center (M.G.A., S.S., C.G.L., L.M., A.Q., L.R.), Neurology and Radiology; UTHealth McGovern Medical School (S.B., F.S.), Neurosurgery, Houston TX; The Royal Melbourne Hospitals (G.S., N.Y., L.C., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Neurology; The Walter and Eliza Hall Institute of Medical Research (N.Y.), Population Health and Immunity, Parkville, Victoria; Royal Adelaide Hospital (T.J.K.), Neurology, Adelaide, South Australia; Gold Coast University Hospital (D.G.S.), Neurology, Southport, Queensland, Australia; Christchurch Hospital (T.Y.W.), Neurology, Christchurch, Canterbury, New Zealand; Cleveland Clinic (M.S.H., G.T., M.A.A.), Cerebrovascular Unit, OH; University of Iowa Hospitals (S.O.G.), Neurosurgery; Baptist Health (A.N.A.), Lyerly Neurosurgery, Jacksonville, FL; Emory University (D.C.H., R.G.N.), Neurology, Atlanta, GA; Riverside Methodist Hospital (R.F.B., W.H., N.V.), Colombia, OH; Saint Louis University (R.C.E.), Neurology, MO; University of Tabuk (T.A.), Neurology, KSA; Baylor Scott & White Health (O.M.), Neurology, Dallas, TX; Greensboro | Cone Health (A.A.), Neurology, Greensboro, NC; Touro Infirmary and New Orleans East Hospital (S.M.-S.), Neurology, LA; UTHealth McGovern Medical School (C.W.S.), Diagnostic and Interventional Radiology, Houston, TX; WellStar Health System (R.G.), Neurology, Marietta, GA; and Memorial Hermann Hospital Texas Medical Center (J.C.G.), Neurology, Houston, TX
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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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Bertog SC, Sievert K, Grunwald IQ, Sharma A, Hornung M, Kühn AL, Vaskelyte L, Hofmann I, Gafoor S, Reinartz M, Matic P, Sievert H. Acute Stroke Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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15
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Wagner B, Lorscheider J, Wiencierz A, Blackham K, Psychogios M, Bolliger D, De Marchis GM, Engelter ST, Lyrer P, Wright PR, Fischer U, Mordasini P, Nannoni S, Puccinelli F, Kahles T, Bianco G, Carrera E, Luft AR, Cereda CW, Kägi G, Weber J, Nedeltchev K, Michel P, Gralla J, Arnold M, Bonati LH. Endovascular Treatment for Acute Ischemic Stroke With or Without General Anesthesia: A Matched Comparison. Stroke 2022; 53:1520-1529. [PMID: 35341319 PMCID: PMC10082068 DOI: 10.1161/strokeaha.121.034934] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endovascular treatment in large artery occlusion stroke reduces disability. However, the impact of anesthesia type on clinical outcomes remains uncertain. METHODS We compared consecutive patients in the Swiss Stroke Registry with anterior circulation stroke receiving endovascular treatment with or without general anesthesia (GA). The primary outcome was disability on the modified Rankin Scale after 3 months, analyzed with ordered logistic regression. Secondary outcomes included dependency or death (modified Rankin Scale score ≥3), National Institutes of Health Stroke Scale after 24 hours, symptomatic intracranial hemorrhage with ≥4 points worsening on National Institutes of Health Stroke Scale within 7 days, and mortality. Coarsened exact matching and propensity score matching were performed to adjust for indication bias. RESULTS One thousand two hundred eighty-four patients (GA: n=851, non-GA: n=433) from 8 Stroke Centers were included. Patients treated with GA had higher modified Rankin Scale scores after 3 months than patients treated without GA, in the unmatched (odds ratio [OR], 1.75 [1.42-2.16]; P<0.001), the coarsened exact matching (n=332-524, using multiple imputations of missing values; OR, 1.60 [1.08-2.36]; P=0.020), and the propensity score matching analysis (n=568; OR, 1.61 [1.20-2.15]; P=0.001). In the coarsened exact matching analysis, there were no significant differences in National Institutes of Health Stroke Scale after 1 day (estimated coefficient 2.61 [0.59-4.64]), symptomatic intracranial hemorrhage (OR, 1.06 [0.30-3.75]), dependency or death (OR, 1.42 [0.91-2.23]), or mortality (OR, 1.65 [0.94-2.89]). In the propensity score matching analysis, National Institutes of Health Stroke Scale after 24 hours (estimated coefficient, 3.40 [1.76-5.04]), dependency or death (OR, 1.49 [1.07-2.07]), and mortality (OR, 1.65 [1.11-2.45]) were higher in the GA group, whereas symptomatic intracranial hemorrhage did not differ significantly (OR, 1.77 [0.73-4.29]). CONCLUSIONS This large study showed worse functional outcome after endovascular treatment of anterior circulation stroke with GA than without GA in a real-world setting. This finding appears to be independent of known differences in patient characteristics between groups.
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Affiliation(s)
- Benjamin Wagner
- Department of Neurology (B.W., J.L., G.M.D.M., S.T.E., P.L., L.H.B.), University Hospital Basel and University of Basel, Switzerland
| | - Johannes Lorscheider
- Department of Neurology (B.W., J.L., G.M.D.M., S.T.E., P.L., L.H.B.), University Hospital Basel and University of Basel, Switzerland
| | - Andrea Wiencierz
- Clinical Trial Unit (A.W., P.R.W.), University Hospital Basel and University of Basel, Switzerland
| | - Kristine Blackham
- Institute of Diagnostic and Interventional Neuroradiology (K.B., M.P.), University Hospital Basel and University of Basel, Switzerland
| | - Marios Psychogios
- Institute of Diagnostic and Interventional Neuroradiology (K.B., M.P.), University Hospital Basel and University of Basel, Switzerland
| | - Daniel Bolliger
- Department of Anesthesiology (D.B.), University Hospital Basel and University of Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology (B.W., J.L., G.M.D.M., S.T.E., P.L., L.H.B.), University Hospital Basel and University of Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology (B.W., J.L., G.M.D.M., S.T.E., P.L., L.H.B.), University Hospital Basel and University of Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatic Medicine FELIX PLATTER and Department of Clinical Research, University of Basel, Switzerland (S.T.E.)
| | - Philippe Lyrer
- Department of Neurology (B.W., J.L., G.M.D.M., S.T.E., P.L., L.H.B.), University Hospital Basel and University of Basel, Switzerland
| | - Patrick R Wright
- Clinical Trial Unit (A.W., P.R.W.), University Hospital Basel and University of Basel, Switzerland
| | - Urs Fischer
- Department of Neurology (U.F., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Stefania Nannoni
- Department of Neurology, Lausanne University Hospital, Switzerland (S.N., F.P., P.M.)
| | - Francesco Puccinelli
- Department of Neurology, Lausanne University Hospital, Switzerland (S.N., F.P., P.M.)
| | - Timo Kahles
- Department of Neurology, Cantonal Hospital Aarau, Switzerland (T.K., K.N.)
| | - Giovanni Bianco
- Stroke Center EOC, Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano (G.B., C.W.C.)
| | - Emmanuel Carrera
- Department of Neurology, University Hospital Geneva, Switzerland (E.C.)
| | - Andreas R Luft
- Department of Neurology, University Hospital Zurich, Switzerland (A.R.L.).,Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland (A.R.L.)
| | - Carlo W Cereda
- Stroke Center EOC, Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano (G.B., C.W.C.)
| | - Georg Kägi
- Department of Neurology (G.K.), Cantonal Hospital St. Gallen, Switzerland
| | - Johannes Weber
- Institute of Diagnostic and Interventional Neuroradiology (J.W.), Cantonal Hospital St. Gallen, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Cantonal Hospital Aarau, Switzerland (T.K., K.N.)
| | - Patrik Michel
- Institute of Diagnostic and Interventional Neuroradiology (P.M., J.G.), Inselspital, Bern University Hospital, University of Bern, Switzerland.,Department of Neurology, Lausanne University Hospital, Switzerland (S.N., F.P., P.M.)
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology (P.M., J.G.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology (U.F., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Leo H Bonati
- Department of Neurology (B.W., J.L., G.M.D.M., S.T.E., P.L., L.H.B.), University Hospital Basel and University of Basel, Switzerland.,Research Department, Reha Rheinfelden, Switzerland (L.H.B.)
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General Anesthesia versus Sedation, Both with Hemodynamic Control, during Intraarterial Treatment for Stroke: The GASS Randomized Trial. Anesthesiology 2022; 136:567-576. [PMID: 35226737 DOI: 10.1097/aln.0000000000004142] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND It is speculated that the anesthetic strategy during endovascular therapy for stroke may have an impact on the outcome of the patients. The authors hypothesized that conscious sedation is associated with a better functional outcome 3 months after endovascular therapy for the treatment of stroke compared with general anesthesia. METHODS In this single-blind, randomized trial, patients received either a standardized general anesthesia or a standardized conscious sedation. Blood pressure control was also standardized in both groups. The primary outcome measure was a modified Rankin score less than or equal to 2 (0 = no symptoms; 5 = severe disability) assessed 3 months after treatment. The main secondary outcomes were complications, mortality, reperfusion results, and National Institutes of Health Stroke Scores at days 1 and 7. RESULTS Of 351 randomized patients, 345 were included in the analysis. The primary outcome occurred in 129 of 341 (38%) of the patients: 63 (36%) in the conscious sedation group and 66 (40%) in the general anesthesia group (relative risk, 0.91 [95% CI, 0.69 to 1.19]; P = 0.474). Patients in the general anesthesia group experienced more intraoperative hypo- or hypertensive episodes, while the cumulative duration was not different (mean ± SD, 36 ± 31 vs. 39 ± 25 min; P = 0.079). The time from onset and from arrival to puncture were longer in the general anesthesia group (mean difference, 19 min [i.e., -00:19] [95% CI, -0:38 to 0] and mean difference, 9 min [95% CI, -0:18 to -0:01], respectively), while the time from onset to recanalization was similar in both groups. Recanalization was more often successful in the general anesthesia group (144 of 169 [85%] vs. 131 of 174 [75%]; P = 0.021). The incidence of symptomatic intracranial hemorrhage was similar in both groups. CONCLUSIONS The functional outcomes 3 months after endovascular treatment for stroke were similar with general anesthesia and sedation. Our results, therefore, suggest that clinicians can use either approach. EDITOR’S PERSPECTIVE
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Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [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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18
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Simonsen CZ, Bösel J, Rasmussen M. Periprocedural Management During Stroke Thrombectomy. Neurology 2021; 97:S105-S114. [PMID: 34785609 DOI: 10.1212/wnl.0000000000012798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 02/24/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF REVIEW Endovascular therapy (EVT) for acute ischemic stroke caused by large vessel occlusion is a powerful and evidence-based tool to achieve reperfusion and results in improved neurologic outcome. Focus has now shifted toward optimizing the procedure. We reviewed the relevant current literature on periprocedural stroke care such as pretreatment with IV tissue plasminogen activator (tPA), choice of anesthesia, ventilation strategy, and blood pressure management. RECENT FINDINGS IV tPA should not be withheld in a patients with stroke eligible for EVT. A meta-analysis of randomized trials on general anesthesia (GA) vs procedural sedation has shown better neurologic outcomes with protocol-based GA in centers with dedicated neuroanesthesia teams. There are no data from randomized trials on blood pressure control, but according to available evidence, systolic blood pressure should probably be held at >140 mm Hg during the procedure and <160 mm Hg after reperfusion. In ventilated patients, extreme deviations from normoxemia and normocapnia should be avoided. SUMMARY Periprocedural care influences the outcome after EVT for large vessel ischemic stroke. More evidence from prospective ongoing and future studies is urgently needed to identify its optimization.
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Affiliation(s)
- Claus Z Simonsen
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany.
| | - Julian Bösel
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany
| | - Mads Rasmussen
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany
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Baldassari MP, Mouchtouris N, Velagapudi L, Nauheim D, Sweid A, Saiegh FA, Khanna O, Ghosh R, Herman M, Wyler D, Gooch MR, Tjoumakaris S, Jabbour P, Rosenwasser R, Romo V. Comparison of Anesthetic Agents Dexmedetomidine and Midazolam During Mechanical Thrombectomy. J Stroke Cerebrovasc Dis 2021; 30:106117. [PMID: 34656971 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/02/2021] [Accepted: 09/10/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The ideal anesthetic for mechanical thrombectomy (MT) is a subject of debate. Recent studies have supported the use of monitored anesthesia care (MAC), but few have attempted to compare MAC neuroanesthetics. Our study directly compares midazolam and dexmedetomidine (DEX) on blood pressure control during thrombectomy and functional outcomes at discharge. MATERIALS AND METHODS We performed a retrospective review of an MT database, which consisted of 612 patients admitted between 2010-2019 to our tertiary stroke center. 193 patients who received either midazolam or DEX for MAC induction were identified. Primary and secondary outcomes were >20% maximum decrease in mean arterial pressure during MT and functional independence respectively. RESULTS 146 patients were administered midazolam, while 47 were administered DEX. Decrease in blood pressure (BP) during MT was associated with lower rates of functional independence at last follow-up (p=0.034). When compared to midazolam, DEX had significantly higher rates of intraprocedural decrease in MAP at the following cut-offs: >20% (p<0.001), >30% (p=0.001), and >40% (p=0.006). On multivariate analysis, DEX was an independent predictor of >20% MAP decrease (OR 7.042, p<0.001). At time of discharge, NIHSS scores and functional independence (mRS 0-2) were statistically similar between DEX and midazolam. Functional independence at last known follow-up was statistically similar between DEX and midazolam (p = 0.643). CONCLUSIONS Use of DEX during MT appears to be associated with increased blood pressure volatility when compared to midazolam. Further investigation is needed to determine the impact of MAC agents on functional independence.
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Affiliation(s)
- Michael P Baldassari
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Lohit Velagapudi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - David Nauheim
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Ritam Ghosh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Mary Herman
- Department of Anesthesiology, Division of Neurological Anesthesia, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - David Wyler
- Department of Anesthesiology, Division of Neurological Anesthesia, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Robert Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Victor Romo
- Department of Anesthesiology, Division of Neurological Anesthesia, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107.
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21
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Is General Anesthesia for Endovascular Thrombectomy Helpful or Harmful? Can J Neurol Sci 2021; 49:746-760. [PMID: 34511142 DOI: 10.1017/cjn.2021.218] [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: 11/06/2022]
Abstract
Endovascular thrombectomy (EVT) has significantly improved outcomes for patients with acute ischemic stroke due to large vessel occlusion. However, despite advances, more than half of patients remain functionally dependent 3 months after their initial stroke. Anesthetic strategy may influence both the technical success of the procedure and overall outcomes. Conventionally, general anesthesia (GA) has been widely used for neuroendovascular procedures, particularly for the distal intracranial circulation, because the complete absence of movement has been considered imperative for procedural success and to minimize complications. In contrast, in patients with acute stroke undergoing EVT, the optimal anesthetic strategy is controversial. Nonrandomized studies suggest GA negatively affects outcomes while the more recent anesthesia-specific RCTs report improved or unchanged outcomes in patients managed with versus without GA, although these findings cannot be generalized to other EVT capable centers due to a number of limitations. Potential explanations for these contrasting results will be addressed in this review including the effect of different anesthetic strategies on cerebral and systemic hemodynamics, revascularization times, and periprocedural complications.
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22
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Fischer C, Vulcu S, Goldberg J, Wagner F, Rodriguez B, Söll N, Mordasini P, Haenggi M, Schefold JC, Raabe A, Z'Graggen WJ. Anesthesia modality does not affect clinical outcomes of intra-arterial vasodilator treatment in patients with symptomatic cerebral vasospasms. F1000Res 2021; 10:417. [PMID: 34394915 PMCID: PMC8356260 DOI: 10.12688/f1000research.52324.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Delayed cerebral ischemia and cerebral vasospasm remain the leading causes of poor outcome in survivors of aneurysmal subarachnoid hemorrhage. Refractory cerebral vasospasms can be treated with endovascular vasodilator therapy, which can either be performed in conscious sedation or general anesthesia. The aim of this study is to compare the effect of the anesthesia modality on long-term clinical outcomes in patients undergoing endovascular vasodilator therapy due to cerebral vasospasm and hypoperfusion. Methods: Modified Rankin Scale (mRS) scores were retrospectively analyzed at time of discharge from the hospital and six months after aneurysmal subarachnoid hemorrhage. Additionally, National Institutes of Health Stroke Scale (NIHSS) was assessed 24 hours before, immediately before, immediately after, and 24 hours after endovascular vasodilator therapy, and at discharge and six months. Interventional parameters such as duration of intervention, choice and dosage of vasodilator and number of arteries treated were also recorded. Results: A total of 98 patients were included in this analysis and separated into patients who had interventions in conscious sedation, general anesthesia and a mix of both. Neither mRS at discharge nor at six months showed a significant difference for functionally independent outcomes (mRS 0-2) between groups. NIHSS before endovascular vasodilator therapy was significantly higher in patients receiving interventions in general anesthesia but did not differ anymore between groups six months after the initial bleed. Conclusion: This study did not observe a difference in outcome whether patients underwent endovascular vasodilator therapy in general anesthesia or conscious sedation for refractory cerebral vasospasms. Hence, the choice should be made for each patient individually.
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Affiliation(s)
- Corinne Fischer
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
| | - Sonja Vulcu
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
| | - Franca Wagner
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
| | - Belén Rodriguez
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
| | - Pasquale Mordasini
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, 3010, Switzerland
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Collette SL, Uyttenboogaart M, Samuels N, van der Schaaf IC, van der Worp HB, Luijckx GJR, Venema AM, Sahinovic MM, Dierckx RAJO, Lingsma HF, Kappen TH, Bokkers RPH. Hypotension during endovascular treatment under general anesthesia for acute ischemic stroke. PLoS One 2021; 16:e0249093. [PMID: 34161331 PMCID: PMC8221480 DOI: 10.1371/journal.pone.0249093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/10/2021] [Indexed: 12/03/2022] Open
Abstract
Objective The effect of anesthetic management (general anesthesia [GA], conscious sedation, or local anesthesia) on functional outcome and the role of blood pressure management during endovascular treatment (EVT) for acute ischemic stroke is under debate. We aimed to determine whether hypotension during EVT under GA is associated with functional outcome at 90 days. Methods We retrospectively collected data from patients with a proximal intracranial occlusion of the anterior circulation treated with EVT under GA. The primary outcome was the distribution on the modified Rankin Scale at 90 days. Hypotension was defined using two thresholds: a mean arterial pressure (MAP) of 70 mm Hg and a MAP 30% below baseline MAP. To quantify the extent and duration of hypotension, the area under the threshold (AUT) was calculated using both thresholds. Results Of the 366 patients included, procedural hypotension was observed in approximately half of them. The occurrence of hypotension was associated with poor functional outcome (MAP <70 mm Hg: adjusted common odds ratio [acOR], 0.57; 95% confidence interval [CI], 0.35–0.94; MAP decrease ≥30%: acOR, 0.76; 95% CI, 0.48–1.21). In addition, an association was found between the number of hypotensive periods and poor functional outcome (MAP <70 mm Hg: acOR, 0.85 per period increase; 95% CI, 0.73–0.99; MAP decrease ≥30%: acOR, 0.90 per period; 95% CI, 0.78–1.04). No association existed between AUT and functional outcome (MAP <70 mm Hg: acOR, 1.000 per 10 mm Hg*min increase; 95% CI, 0.998–1.001; MAP decrease ≥30%: acOR, 1.000 per 10 mm Hg*min; 95% CI, 0.999–1.000). Conclusions Occurrence of procedural hypotension and an increase in number of procedural hypotensive periods were associated with poor functional outcome, whereas the extent and duration of hypotension were not. Randomized clinical trials are needed to confirm our hypothesis that hypotension during EVT under GA has detrimental effects.
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Affiliation(s)
- Sabine L. Collette
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- * E-mail:
| | - Maarten Uyttenboogaart
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Noor Samuels
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert Jan R. Luijckx
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Allart M. Venema
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marko M. Sahinovic
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rudi A. J. O. Dierckx
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Teus H. Kappen
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Shen H, Ma X, Wu Z, Shao X, Cui J, Zhang B, Abdelrahim ME, Zhang J. Conscious sedation compared to general anesthesia for intracranial mechanical thrombectomy: A meta-analysis. Brain Behav 2021; 11:e02161. [PMID: 33960706 PMCID: PMC8213640 DOI: 10.1002/brb3.2161] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Endovascular therapy is the standard of care for severe acute ischemic stroke caused by large-vessel occlusion in the anterior circulation, but there is a debate on the optimal anesthetic approach during this therapy. Meta-analyses of observational studies suggest that general anesthesia increases disability and death compared with conscious sedation However, their results are conflicting. This meta-analysis study was performed to assess the relationship between the effects of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke. METHODS Through a systematic literature search up to August 2020, 18 studies included 4,802 subjects at baseline with endovascular therapy for acute ischemic stroke and reported a total of 1,711 subjects using general anesthesia and 1,961 subjects using conscious sedation were found. They recorded relationships between the effects of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke. Odds ratio (OR) or Mean differences (MD) with 95% confidence intervals (CIs) were calculated between the effect of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke using the dichotomous or contentious methods with a random or fixed-effect model. RESULTS No significant difference were found between general anesthesia and conscious sedation during the endovascular therapy for acute ischemic stroke in functional independence at 90 days (OR, 0.78; 95% CI, 0.44-1.40, p = 40); successful recanalization at 24 hr (OR, 1.23; 95% CI, 0.62-2.41, p = 55); mortality at 90 days (OR, 1.36; 95% CI, 0.83-2.24, p = .22); interventional complication (OR, 1.24; 95% CI, 0.76-2.02, p = .40); symptomatic intracranial hemorrhage (OR, 0.64; 95% CI, 0.41-0.99, p = .05); aspiration pneumonia (OR, 0.96; 95% CI, 0.58-1.58, p = .87); and National Institute of Health Stroke Scale score after 24 hr (MD, 0.38; 95% CI, -1.15-1.91, p = .62); with relative relationship favoring general anesthesia only in decreasing the symptomatic intracranial hemorrhage. CONCLUSIONS General anesthesia has no independent relationship compared to conscious sedation during the endovascular therapy for acute ischemic stroke with a relative relationship favoring general anesthesia only in decreasing the symptomatic intracranial hemorrhage. This relationship encouraged us to recommend either anesthetic strategy during the endovascular therapy for acute ischemic stroke with no possible fear of higher complication.
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Affiliation(s)
- Huasu Shen
- Department of Anesthesiology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, China
| | - Xiaoyu Ma
- Department of Anesthesiology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, China
| | - Zhen Wu
- Department of Anesthesiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xian Shao
- Department of Anesthesiology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, China
| | - Jingjing Cui
- Department of Anesthesiology, Cangzhou Hospital of Integrated TCM-WM·Hebei, Cangzhou, China
| | - Bao Zhang
- Department of Anesthesiology, Cangzhou Hospital of Integrated TCM-WM·Hebei, Cangzhou, China
| | - Mohamed Ea Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Jin Zhang
- Department of Anesthesiology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, China
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Chen M, Kronsteiner D, Pfaff JAR, Schieber S, Bendszus M, Kieser M, Wick W, Möhlenbruch MA, Ringleb PA, Bösel J, Schönenberger S. Emergency intubation during thrombectomy for acute ischemic stroke in patients under primary procedural sedation. Neurol Res Pract 2021; 3:27. [PMID: 34001285 PMCID: PMC8130257 DOI: 10.1186/s42466-021-00125-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/04/2021] [Indexed: 11/30/2022] Open
Abstract
Background Emergency intubation is an inherent risk of procedural sedation regimens for endovascular treatment (EVT) of acute ischemic stroke. We aimed to characterize the subgroup of patients, who had to be emergently intubated, to identify predictors of the need for intubation and assess their outcomes. Methods This is a retrospective analysis of the single-center study KEEP SIMPLEST, which evaluated a new in-house SOP for EVT under primary procedural sedation. We used descriptive statistics and regression models to examine predictors and functional outcome of emergently intubated patients. Results Twenty of 160 (12.5%) patients were emergently intubated. National Institutes of Health Stroke Scale (NIHSS) on admission, premorbid modified Rankin scale (mRS), Alberta Stroke Program Early CT Score, age and side of occlusion were not associated with need for emergency intubation. Emergency intubation was associated with a lower rate of successful reperfusion (OR, 0.174; 95%-CI, 0.045 to 0.663; p = 0.01). Emergently intubated patients had higher in-house mortality (30% vs 6.4%; p = 0.001) and a lower rate of mRS 0–2 at 3 months was observed in those patients (10.5% vs 37%, p = 0.024). Conclusions Emergency intubation during a primary procedural sedation regimen for EVT was associated with lower rate of successful reperfusion. Less favorable outcome was observed in the subgroup of emergently intubated patients. More research is required to find practical predictors of intubation need and to determine, whether emergency intubation is safe under strict primary procedural sedation regimens for EVT. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00125-0.
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Affiliation(s)
- Min Chen
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg, Germany.
| | - Dorothea Kronsteiner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Johannes A R Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Schieber
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg, Germany.,Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg, Germany
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Does General Anesthesia Compared With Conscious Sedation Result in Better Outcomes in Acute Stroke Patients Undergoing Endovascular Therapy? Neurologist 2021; 26:47-51. [PMID: 33646989 DOI: 10.1097/nrl.0000000000000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is considerable controversy surrounding the optimal use of sedation in patients with acute ischemic stroke undergoing mechanical thrombectomy. Several retrospective studies have favored conscious sedation (CS) over general anesthesia (GA) in terms of functional outcomes and mortality. Recent data from randomized controlled trials has challenged this view. OBJECTIVE The aim was to critically assess current evidence regarding the use of CS versus GA in mechanical thrombectomy for acute ischemic stroke. METHODS The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular neurology, vascular neurosurgery, and interventional neuroradiology. RESULTS A randomized controlled trial was selected for critical appraisal. This trial compared 128 patients with acute ischemic stroke and large vessel occlusion from a single center (Aarhus University Hospital, Denmark), 65 of whom received GA and 63 received CS. No significant difference was detected for the primary outcome of volume of infarct growth. The rate of successful thrombectomy and favorable clinical outcomes for the GA arm was significantly higher in the intention-to-treat analysis. CONCLUSIONS GA does not result in worse tissue outcomes or worse clinical outcomes when compared with CS in acute stroke patients with large vessel occlusion undergoing mechanical thrombectomy.
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Rasmussen M, Schönenberger S, Hendèn PL, Valentin JB, Espelund US, Sørensen LH, Juul N, Uhlmann L, Johnsen SP, Rentzos A, Bösel J, Simonsen CZ. Blood Pressure Thresholds and Neurologic Outcomes After Endovascular Therapy for Acute Ischemic Stroke: An Analysis of Individual Patient Data From 3 Randomized Clinical Trials. JAMA Neurol 2021; 77:622-631. [PMID: 31985746 DOI: 10.1001/jamaneurol.2019.4838] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance The optimal blood pressure targets during endovascular therapy (EVT) for acute ischemic stroke (AIS) are unknown. Objective To study whether procedural blood pressure parameters, including specific blood pressure thresholds, are associated with neurologic outcomes after EVT. Design, Setting, and Participants This retrospective cohort study included adults with anterior-circulation AIS who were enrolled in randomized clinical trials assessing anesthetic strategy for EVT between February 2014 and February 2017. The trials had comparable blood pressure protocols, and patients were followed up for 90 days. A total of 3630 patients were initially approached, and 3265 patients were excluded. Exposure Endovascular therapy. Main Outcomes and Measures The primary efficacy variable was functional outcome as defined by the modified Rankin Scale (mRS) score at 90 days. Associations of blood pressure parameters and time less than and greater than mean arterial blood pressure (MABP) thresholds with outcome were analyzed. Results Of the 365 patients included in the analysis, the mean (SD) age was 71.4 (13.0) years, 163 were women (44.6%), and the median National Institutes of Health Stroke Scale score was 17 (interquartile range [IQR], 14-21). For the entire cohort, 182 (49.9%) received general anesthesia and 183 (50.1%) received procedural sedation. A cumulated period of minimum 10 minutes with less than 70 mm Hg MABP (adjusted OR, 1.51; 95% CI, 1.02-2.22) and a continuous episode of minimum 20 minutes with less than 70 mm Hg MABP (adjusted OR, 2.30; 95% CI, 1.11-4.75) were associated with a shift toward higher 90-day mRS scores, corresponding to a number needed to harm of 10 and 4, respectively. A cumulated period of minimum 45 minutes with greater than 90 mm Hg MABP (adjusted OR, 1.49; 95% CI, 1.11-2.02) and a continuous episode of minimum 115 minutes with greater than 90 mm Hg MABP (adjusted OR, 1.89; 95% CI, 1.01-3.54) were associated with a shift toward higher 90-day mRS scores, corresponding to a number needed to harm of 10 and 6, respectively. Conclusions and Relevance Critical MABP thresholds and durations for poor outcome were found to be MABP less than 70 mm Hg for more than 10 minutes and MABP greater than 90 mm Hg for more than 45 minutes, both durations with a number needed to harm of 10 patients. Mean arterial blood pressure may be a modifiable therapeutic target to prevent or reduce poor functional outcome after EVT.
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Affiliation(s)
- Mads Rasmussen
- Department of Anesthesia, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | | | - Pia Löwhagen Hendèn
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan B Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Ulrick S Espelund
- Department of Anesthesiology and Intensive Care Medicine, Regional Hospital in Horsens, Horsens, Denmark
| | - Leif H Sørensen
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Juul
- Department of Anesthesia, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Alexandros Rentzos
- Department of Radiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Julian Bösel
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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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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Diprose WK, Wang MTM, Campbell D, Sutcliffe JA, McFetridge A, Chiou D, Lai J, Barber PA. Intravenous Propofol Versus Volatile Anesthetics For Stroke Endovascular Thrombectomy. J Neurosurg Anesthesiol 2021; 33:39-43. [PMID: 31453877 DOI: 10.1097/ana.0000000000000639] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The choice of anesthetic technique for ischemic stroke patients undergoing endovascular thrombectomy is controversial. Intravenous propofol and volatile inhalational general anesthetic agents have differing effects on cerebral hemodynamics, which may affect ischemic brain tissue and clinical outcome. We compared outcomes in patients undergoing endovascular thrombectomy with general anesthesia who were treated with propofol or volatile agents. METHODS Consecutive endovascular thrombectomy patients treated using general anesthesia were identified from our prospective database. Baseline patient characteristics, anesthetic agent, and clinical outcomes were recorded. Functional independence at 3 months was defined as a modified Rankin Scale of 0 to 2. RESULTS There were 313 patients (182 [58.1%] men; mean±SD age, 64.7±15.9 y; 257 [82%] anterior circulation), of whom 254 (81%) received volatile inhalational (desflurane or sevoflurane), and 59 (19%) received intravenous propofol general anesthesia. Patients with propofol anesthesia had more ischemic heart disease, higher baseline National Institutes of Health Stroke Scale scores, more basilar artery occlusion, and were less likely to be treated with intravenous thrombolysis. Multivariable logistic regression analysis showed that propofol anesthesia was associated with improved functional independence at 3 months (odds ratio=2.65; 95% confidence interval, 1.14-6.22; P=0.03) and a nonsignificant trend toward reduced 3-month mortality (odds ratio=0.37; 95% CI, 0.12-1.10; P=0.07). CONCLUSION In stroke patients undergoing endovascular thrombectomy treated using general anesthesia, there may be a differential effect between intravenous propofol and volatile inhalational agents. These results should be considered hypothesis-generating and be tested in future randomized controlled trials.
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Affiliation(s)
- William K Diprose
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland
- Departments of Neurology
| | - Michael T M Wang
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland
| | | | | | | | | | | | - P Alan Barber
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland
- Departments of Neurology
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Patel P, Yavagal D, Khandelwal P. Hyperacute Management of Ischemic Strokes: JACC Focus Seminar. J Am Coll Cardiol 2020; 75:1844-1856. [PMID: 32299596 DOI: 10.1016/j.jacc.2020.03.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/03/2020] [Accepted: 03/06/2020] [Indexed: 11/16/2022]
Abstract
Acute ischemic stroke is the leading cause of disability and among the leading causes of mortality worldwide. Intravenous tissue plasminogen activator has been a cornerstone for treatment of acute ischemic stroke for more than 20 years; however, its use is limited due to a narrow therapeutic window, several contraindications, and low efficacy to recanalize the artery in large vessel occlusion. Recently, the addition of endovascular mechanical thrombectomy of large artery occlusion has revolutionized the stroke treatment for most disabling strokes. The paper reviews updates to the thrombolytic treatment as well as catheter-based treatment, and results from recent trials in the selection of patients in an extended time window using perfusion imaging.
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Affiliation(s)
- Pratit Patel
- Departments of Neurological Surgery, Rutgers University-New Jersey Medical School, Newark, New Jersey
| | - Dileep Yavagal
- Department of Neurology and Neurological Surgery, Jackson Memorial & University of Miami Hospitals, University of Miami Miller School of Medicine, Miami, Florida
| | - Priyank Khandelwal
- Departments of Neurological Surgery, Rutgers University-New Jersey Medical School, Newark, New Jersey.
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Abstract
PURPOSE OF REVIEW This article reviews the actual indications for mechanical thrombectomy in patients with acute ischemic stroke and how the opportunities for endovascular therapy can be expanded by using the concept of clinical-imaging or perfusion-imaging mismatch (as a surrogate for salvageable tissue) rather than time of ischemia. RECENT FINDINGS Six randomized controlled trials undoubtedly confirmed the benefits of using endovascular thrombectomy on the clinical outcome of patients with stroke with large vessel occlusion within 6 hours from symptom onset compared with those receiving only standard medical care. In a meta-analysis of individual patient data, the number needed to treat with endovascular thrombectomy to reduce disability by at least one level on the modified Rankin Scale for one patient was 2.6. Recently, the concept of "tissue window" versus time window has proved useful for selecting patients for mechanical thrombectomy up to 24 hours from symptom onset. The DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention) trial included patients at a median of 12.5 hours from onset and showed the largest effect in functional outcome ever described in any acute stroke treatment trial (35.5% increase in functional independence). In DEFUSE 3 (Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 3), patients treated with mechanical thrombectomy at a median of 11 hours after onset had a 28% increase in functional independence and an additional 20% absolute reduction in death or severe disability. SUMMARY For patients with acute ischemic stroke and a large vessel occlusion in the proximal anterior circulation who can be treated within 6 hours of stroke symptom onset, mechanical thrombectomy with a second-generation stent retriever or a catheter aspiration device should be indicated regardless of whether the patient received treatment with intravenous (IV) recombinant tissue plasminogen activator (rtPA) in patients with limited signs of early ischemic changes on neuroimaging. Two clinical trials completely disrupted the time window concept in acute ischemic stroke, showing excellent clinical outcomes in patients treated up to 24 hours from symptom onset. Time of ischemia is, on average, a good biomarker for tissue viability; however, the window of opportunity for treatment varies across different individuals because of a range of compensatory mechanisms. Adjusting time to the adequacy of collateral flow leads to the concept of tissue window, a paradigm shift in stroke reperfusion therapy.
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Abstract
Early recanalization of the closed cerebral arteries after acute ischemic stroke (AIS) is the only treatment to minimize long-term disability and to reduce the associated morbidity and mortality. For a long time the only proven causal treatment of AIS was intravenous thrombolysis; however, after the publication of a series of randomized prospective studies concerning endovascular mechanical thrombectomy using stent retriever systems after AIS, new guidelines were published. It was found that endovascular treatment (EVT) dramatically improves the outcome of eligible patients. The stent retriever enables high recanalization rates by clot removal from the cerebral arterial system by means of aspiration of the thrombus via the catheter and/or by entrapping it with a stent system. The management of anesthesia during the procedure is indispensable to prevent hypoxia and hemodynamic instability; however, which form of anesthesia (i.e. general anesthesia vs. conscious sedation) is advantageous for the patient during EVT is controversially discussed. In the first studies using retrospective data conscious sedation resulted in a better outcome compared to general anesthesia following EVT; however, in prospective studies this finding could not be confirmed. To obtain optimal neurological results after AIS and EVT with general anesthesia, it is of tremendous importance not to delay the EVT due to the anesthesiology procedure. Furthermore, hypotension, hypovolemia and hypocapnia should also be strictly avoided. Finally, the optimal anesthesiological approach should be guided by the current clinical state and pre-existing comorbidities of the patient.
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Affiliation(s)
- H J Theilen
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl-Gustav-Carus, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - J C Gerber
- Institut und Poliklinik für Neuroradiologie, Universitätsklinikum Carl-Gustav-Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
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Fan L, Han W, Zhang Y, Zhou M, Ye H, Chen W, Su Y. Risk factors for ineffective recanalization after endovascular treatment in acute ischemic stroke. Clin Neurol Neurosurg 2020; 200:106362. [PMID: 33243698 DOI: 10.1016/j.clineuro.2020.106362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 10/13/2020] [Accepted: 11/07/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the risk factors of early ineffective recanalization, defined as a modified Rankin scale (mRS) score of 4∼6 at two weeks after symptom onset, in acute ischemic stroke (AIS) patients receiving endovascular treatment (EVT). METHOD One hundred eighty-four AIS patients who received EVT in 01/2016-12/2018 were analyzed. The recanalization rate was 81.5 % (150/184). Patients were divided into effective (mRS 0-3) and ineffective (mRS 4-6) recanalization groups. The independent risk factors for ineffective recanalization were analyzed. RESULT The ineffective recanalization rate was 67.3 % (101/150 cases) at 14 days after symptom onset. Twenty-five patients (24.8 %) in the ineffective recanalization group had coronary heart disease, higher than that in the effective group (4 patients, 8.2 %, P = 0.016). Infratentorial pathology accounted for 34.7 % (35 cases) of the ineffective group and only 14.3 % (7 cases) of the control group (P = 0.011). Systolic blood pressure (SBP) was higher in the ineffective group than in the effective group (146 mmHg vs 140 mmHg, P = 0.038). General anesthesia was more common in the ineffective group than in the control group (49 cases, 48.5 %, vs 9 cases, 18.4 %; P = 0.000). Logistic regression showed that coronary heart disease (odds ratio (OR) = 3.399, 95 % confidence interval (CI) 1.013-11.401, P = 0.048), unconsciousness before EVT (OR = 4.292, 95 % CI 1.963-9.386, P = 0.000), SBP (OR = 1.016, 95 % CI 0.997-1.035, P = 0.090) and general anesthesia (OR = 3.378, 95 % CI 1.395-8.180, P = 0.007) were independent risk factors for ineffective recanalization. CONCLUSION Patients with coronary heart disease, unconsciousness before EVT, elevated SBP and general anesthesia need precise assessment to benefit from EVT.
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Affiliation(s)
- Linlin Fan
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Wei Han
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China; Department of Neurology, Affiliated Hospital of Jiang Su University, Zhejiang, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China.
| | - Meijun Zhou
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China; Department of Neurology, The Fourth Hospital of Changsha, Changsha, China
| | - Hong Ye
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
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Amini M, van Leeuwen N, Eijkenaar F, Mulder MJHL, Schonewille W, Lycklama À Nijeholt G, Hinsenveld WH, Goldhoorn RJB, van Doormaal PJ, Jenniskens S, Hazelzet J, Dippel DWJ, Roozenbeek B, Lingsma HF. Improving quality of stroke care through benchmarking center performance: why focusing on outcomes is not enough. BMC Health Serv Res 2020; 20:998. [PMID: 33129362 PMCID: PMC7603730 DOI: 10.1186/s12913-020-05841-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/20/2020] [Indexed: 11/18/2022] Open
Abstract
Background Between-center variation in outcome may offer opportunities to identify variation in quality of care. By intervening on these quality differences, patient outcomes may be improved. However, whether observed differences in outcome reflect the true quality improvement potential is not known for many diseases. Therefore, we aimed to analyze the effect of differences in performance on structure and processes of care, and case-mix on between-center differences in outcome after endovascular treatment (EVT) for ischemic stroke. Methods In this observational cohort study, ischemic stroke patients who received EVT between 2014 and 2017 in all 17 Dutch EVT-centers were included. Primary outcome was the modified Rankin Scale, ranging from 0 (no symptoms) to 6 (death), at 90 days. We used random effect proportional odds regression modelling, to analyze the effect of differences in structure indicators (center volume and year of admission), process indicators (time to treatment and use of general anesthesia) and case-mix, by tracking changes in tau2, which represents the amount of between-center variation in outcome. Results Three thousand two hundred seventy-nine patients were included. Performance on structure and process indicators varied significantly between EVT-centers (P < 0.001). Predicted probability of good functional outcome (modified Rankin Scale 0–2 at 90 days), which can be interpreted as an overall measure of a center’s case-mix, varied significantly between 17 and 50% across centers. The amount of between-center variation (tau2) was estimated at 0.040 in a model only accounting for random variation. This estimate more than doubled after adding case-mix variables (tau2: 0.086) to the model, while a small amount of between-center variation was explained by variation in performance on structure and process indicators (tau2: 0.081 and 0.089, respectively). This indicates that variation in case-mix affects the differences in outcome to a much larger extent. Conclusions Between-center variation in outcome of ischemic stroke patients mostly reflects differences in case-mix, rather than differences in structure or process of care. Since the latter two capture the real quality improvement potential, these should be used as indicators for comparing center performance. Especially when a strong association exists between those indicators and outcome, as is the case for time to treatment in ischemic stroke. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05841-y.
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Affiliation(s)
- Marzyeh Amini
- Department of Public Health, Erasmus MC University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Nikki van Leeuwen
- Department of Public Health, Erasmus MC University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Frank Eijkenaar
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Maxim J H L Mulder
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wouter Schonewille
- Department of Neurology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Wouter H Hinsenveld
- Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Robert-Jan B Goldhoorn
- Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sjoerd Jenniskens
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Hazelzet
- Department of Public Health, Erasmus MC University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
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Du H, Tong X, Sun X, Shi Z, Liu B, Gao F, Miao Z, Zhang D. Effect of anesthesia strategy during endovascular therapy on 90-day outcomes in acute basilar artery occlusion: a retrospective observational study. BMC Neurol 2020; 20:398. [PMID: 33121454 PMCID: PMC7596928 DOI: 10.1186/s12883-020-01979-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 10/26/2020] [Indexed: 01/18/2023] Open
Abstract
Background and objective The research on the effect of anesthesia on endovascular therapy (EVT) of acute ischemic stroke is mainly focused on the anterior circulation, and little is known about the data of basilar artery occlusion (BAO). This study aims to investigate the association of anesthesia strategy with 90-day clinical outcomes of patients with acute BAO treated with EVT. Methods We reviewed our prospectively collected data from the endovascular treatment database at the Beijing Tiantan Hospital. This included patients with acute BAO who had a documented 90-day modified Rankin Scale (mRS) score from January 2012 to July 2018. Options for EVT included general anesthesia (GA) and conscious sedation (CS) performed by an anesthesia care team in the institution. The recommendation of anesthesia for patients was a joint decision between anesthesiologist and neurointerventionalist according to a pre-designed scheme. Patients who required tracheal intubation for airway protection prior to EVT were excluded. The clinical outcomes we observed were functional independence (mRS ≤2), favorable outcome (mRS ≤3), and mortality at 90 days after the procedure. Univariate and multivariable logistic regression analyses were used to explore the relationship between anesthesia methods and 90-day outcomes. Results A total of 187 patients with BAO were treated by EVT in this study. Nine cases requiring emergent intubation prior to EVT were excluded. 139 patients (78.1%) underwent GA and 39 patients (21.9%) underwent CS. In univariate analysis, GA was associated with less functional independence [odds ratio (OR), 0.28; 95% confidence interval (CI), 0.13–0.59] and less favorable outcome (OR, 0.23; 95% CI, 0.10–0.52) than was CS. After adjusting for potential confounders, multivariable analysis showed that there were still significant differences between GA and CS in functional independence (OR, 0.31; 95%CI, 0.10–0.97) and favorable outcome (OR, 0.24; 95%CI, 0.07–0.75). Conclusion Our retrospective analysis suggested that the anesthesia strategy may affect outcome, in which general anesthesia may result in less favorable outcomes. Nevertheless, future multicenter randomized controlled trials are needed to confirm our findings.
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Affiliation(s)
- Haibin Du
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,Department of Neurosurgery, Peking University Shougang Hospital, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,Department of Neurology, Tangshan Gongren Hospital, Hebei Medical University, Tangshan, Hebei, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Zhiyong Shi
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Bin Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
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Prevalence, Predictors, and Outcomes of Prolonged Mechanical Ventilation After Endovascular Stroke Therapy. Neurocrit Care 2020; 34:1009-1016. [PMID: 33089433 PMCID: PMC7577519 DOI: 10.1007/s12028-020-01125-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 09/30/2020] [Indexed: 11/09/2022]
Abstract
Background To investigate the rates, predictors, and outcomes of prolonged mechanical ventilation (≥ 96 h) following endovascular treatment (EVT) of ischemic stroke. Methods Hospitalizations with acute ischemic stroke and EVT were identified using validated codes in the National Inpatient Sample (2010–2015). The primary outcome was prolonged mechanical ventilation defined as ventilation ≥ 96 consecutive hours. We compared hospitalizations involving prolonged ventilation following EVT with those that did not involve prolonged ventilation. Propensity score matching was used to adjust for differences between groups. Clinical predictors of prolonged ventilation were assessed using multivariable conditional logistic regression analyses. Results Among the 34,184 hospitalizations with EVT, 5087 (14.9%) required prolonged mechanical ventilation. There was a decline in overall intubation and prolonged ventilation during the study period. On multivariable analysis, history of heart failure [OR 1.28 (95% CI 1.05–1.57)] and diabetes [OR 1.22 (95% CI 1–1.50)] was independent predictors of prolonged ventilation following EVT. In a sensitivity analysis of anterior circulation stroke only, heart failure [OR 1.3 (95% CI 1.10–1.61)], diabetes [OR 1.25 (95% CI 1.01–1.57)], and chronic lung disease [OR 1.31 (95% CI 1.03–1.66)] were independent predictors of prolonged ventilation. The weighted proportions of in-hospital mortality, post-procedural shock, acute renal failure, and intracerebral hemorrhage were higher in the prolonged ventilation group. Conclusions Among a nationally representative sample of hospitalizations, nearly one-in-six patients had prolonged mechanical ventilation after EVT. Heart failure and diabetes were significantly associated with prolonged mechanical ventilation following EVT. Prolonged ventilation was associated with significant increase in in-hospital mortality and morbidity. Electronic supplementary material The online version of this article (10.1007/s12028-020-01125-9) contains supplementary material, which is available to authorized users.
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Valent A, Maïer B, Chabanne R, Degos V, Lapergue B, Lukaszewicz AC, Mazighi M, Gayat E. Anaesthesia and haemodynamic management of acute ischaemic stroke patients before, during and after endovascular therapy. Anaesth Crit Care Pain Med 2020; 39:859-870. [PMID: 33039657 DOI: 10.1016/j.accpm.2020.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/16/2020] [Accepted: 05/26/2020] [Indexed: 11/29/2022]
Abstract
Endovascular therapy (EVT) is now standard of care for eligible patients with acute ischaemic stroke caused by large vessel occlusion in the anterior circulation. EVT can be performed with general anaesthesia (GA) or with monitored anaesthesia care, involving local anaesthesia with or without conscious sedation (LA/CS). Controversies remain regarding the optimal choice of anaesthetic strategy and observational studies suggested poorer functional outcome and higher mortality in patients treated under GA, essentially because of its haemodynamic consequences and the delay to put patients under GA. However, these studies are limited by selection bias, the most severe patients being more likely to receive GA and recent randomised trials and meta-analysis showed that protocol-based GA compared with LA/CS is significantly associated with less disability at 3 months. Unlike for intravenous thrombolysis, few data exist to guide management of blood pressure (BP) before and during EVT, but arterial hypotension should be avoided as long as the occlusion persists. BP targets following EVT should probably be adapted to the degree of recanalisation and the extent of ischaemia. Lower BP levels may be warranted to prevent reperfusion injuries even if prospective haemodynamic management evaluations after EVT are lacking.
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Affiliation(s)
- Arnaud Valent
- Department of Anaesthesiology and Critical Care, Lariboisière Hospital, DMU Parabol, AP-HP Nord & University of Paris, Paris, France; UMR-S 942 MASCOT, Inserm, France
| | - Benjamin Maïer
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, 75019 Paris, France
| | - Russell Chabanne
- Department of Perioperative Medicine, University Hospital of Clermont-Ferrand, Clermont-Ferrand Cedex, France
| | - Vincent Degos
- Department of Anaesthesia and Critical Care, Pitié Salpêtrière Hospital, AP-HP-SU, Paris, France, Groupe recherche clinique BIOSFAST, Sorbonne University, Paris, France
| | - Bertrand Lapergue
- Stroke Centre Neurology Division, Hôpital Foch, 92150, Suresnes, France
| | - Anne-Claire Lukaszewicz
- Service d'Anesthésie Réanimation, Hôpital Neurologique, Hospices Civils de Lyon, Bron, France; EA 7426 PI3 (Pathophysiology of Injury-induced Immunosuppression), Hospices Civils de Lyon/Université de Lyon/bioMérieux, Hôpital E. Herriot, Lyon cedex 03, France
| | - Mikael Mazighi
- Department of Neurology and Stroke Centre, Lariboisière Hospital, AP-HP, Paris University, Sorbonne Paris Cité, Paris, France; Département Hospitalo-Universistaire Neurovasc, Paris, France
| | - Etienne Gayat
- Department of Anaesthesiology and Critical Care, Lariboisière Hospital, DMU Parabol, AP-HP Nord & University of Paris, Paris, France; UMR-S 942 MASCOT, Inserm, France.
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Samuels N, van de Graaf RA, van den Berg CAL, Nieboer D, Eralp I, Treurniet KM, Emmer BJ, Immink RV, Majoie CBLM, van Zwam WH, Bokkers RPH, Uyttenboogaart M, van Hasselt BAAM, Mühling J, Burke JF, Roozenbeek B, van der Lugt A, Dippel DWJ, Lingsma HF, van Es ACGM. Blood Pressure During Endovascular Treatment Under Conscious Sedation or Local Anesthesia. Neurology 2020; 96:e171-e181. [PMID: 33028664 PMCID: PMC7905780 DOI: 10.1212/wnl.0000000000011006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 08/24/2020] [Indexed: 12/27/2022] Open
Abstract
Objective To evaluate the role of blood pressure (BP) as mediator of the effect of conscious sedation (CS) compared to local anesthesia (LA) on functional outcome after endovascular treatment (EVT). Methods Patients treated in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry centers with CS or LA as preferred anesthetic approach during EVT for ischemic stroke were analyzed. First, we evaluated the effect of CS on area under the threshold (AUT), relative difference between baseline and lowest procedural mean arterial pressure (∆LMAP), and procedural BP trend, compared to LA. Second, we assessed the association between BP and functional outcome (modified Rankin Scale [mRS]) with multivariable regression. Lastly, we evaluated whether BP explained the effect of CS on mRS. Results In 440 patients with available BP data, patients treated under CS (n = 262) had larger AUTs (median 228 vs 23 mm Hg*min), larger ∆LMAP (median 16% vs 6%), and a more negative BP trend (−0.22 vs −0.08 mm Hg/min) compared to LA (n = 178). Larger ∆LMAP and AUTs were associated with worse mRS (adjusted common odds ratio [acOR] per 10% drop 0.87, 95% confidence interval [CI] 0.78–0.97, and acOR per 300 mm Hg*min 0.89, 95% CI 0.82–0.97). Patients treated under CS had worse mRS compared to LA (acOR 0.59, 95% CI 0.40–0.87) and this association remained when adjusting for ∆LMAP and AUT (acOR 0.62, 95% CI 0.42–0.92). Conclusions Large BP drops are associated with worse functional outcome. However, BP drops do not explain the worse outcomes in the CS group.
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Affiliation(s)
- Noor Samuels
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor.
| | - Rob A van de Graaf
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Carlijn A L van den Berg
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Daan Nieboer
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Ismail Eralp
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Kilian M Treurniet
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Bart J Emmer
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Rogier V Immink
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Charles B L M Majoie
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Wim H van Zwam
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Reinoud P H Bokkers
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Maarten Uyttenboogaart
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Boudewijn A A M van Hasselt
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Jörg Mühling
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - James F Burke
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Bob Roozenbeek
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Aad van der Lugt
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Diederik W J Dippel
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Hester F Lingsma
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Adriaan C G M van Es
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
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Al Kasab S, Almallouhi E, Alawieh A, Levitt MR, Jabbour P, Sweid A, Starke RM, Saini V, Wolfe SQ, Fargen KM, Arthur AS, Goyal N, Pandhi A, Fragata I, Maier I, Matouk C, Grossberg JA, Howard BM, Kan P, Hafeez M, Schirmer CM, Crowley RW, Joshi KC, Tjoumakaris SI, Chowdry S, Ares W, Ogilvy C, Gomez-Paz S, Rai AT, Mokin M, Guerrero W, Park MS, Mascitelli JR, Yoo A, Williamson R, Grande AW, Crosa RJ, Webb S, Psychogios MN, Ducruet AF, Holmstedt CA, Ringer AJ, Spiotta AM. International experience of mechanical thrombectomy during the COVID-19 pandemic: insights from STAR and ENRG. J Neurointerv Surg 2020; 12:1039-1044. [PMID: 32843359 PMCID: PMC7453763 DOI: 10.1136/neurintsurg-2020-016671] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied. METHODS A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders. RESULTS 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015). CONCLUSION We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.
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Affiliation(s)
- Sami Al Kasab
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ali Alawieh
- Neurosurgery, Emory University, Atlanta, Georgia, USA.,Microbiology and Immunology, Medical University of South Carolina, South Carolina, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ahmad Sweid
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami Beach, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Vasu Saini
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nitin Goyal
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Abhi Pandhi
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Jonathan A Grossberg
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brian M Howard
- Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Muhammad Hafeez
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Krishna C Joshi
- Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Shakeel Chowdry
- North Shore University Health System, Evanston, Illinois, USA
| | - William Ares
- Neurosurgery, North Shore University Health System, Evanston, Illinois, USA
| | | | | | - Ansaar T Rai
- Department of Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Waldo Guerrero
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Min S Park
- Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Justin R Mascitelli
- Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Albert Yoo
- Texas Stroke Institute, Fort Worth, Texas, USA
| | - Richard Williamson
- Stroke & Cerebrovascular Center, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Andrew Walker Grande
- Neurosurgery, Radiology and Neurology, University of Minnesota, Mendota Heights, Minnesota, USA
| | | | - Sharon Webb
- Neurosurgery, Bon Secours St Francis Hospital, Greenville, South Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Andrew J Ringer
- Neurosurgery, Mayfield Clinic, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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40
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Xu H, Jia B, Huo X, Mo D, Ma N, Gao F, Yang M, Miao Z. Predictors of Futile Recanalization After Endovascular Treatment in Patients with Acute Ischemic Stroke in a Multicenter Registry Study. J Stroke Cerebrovasc Dis 2020; 29:105067. [PMID: 32912569 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105067] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/28/2020] [Accepted: 06/14/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Futile recanalization, defined as the early recanalization of an occluded artery failing to improve neurological outcome, remains a persistent concern in the endovascular treatment of acute ischemic stroke. We investigated the occurrence and predictors of futile recanalization after endovascular treatment in a nationwide multicenter stroke registry study. METHODS The subjects consisted of eligible patients from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment registry study (2015-2017). Subjects with acute anterior large vessel occlusion who achieved successful angiographic recanalization (defined as modified Thrombolysis in Cerebral Infarction grades 2b or 3) by endovascular treatment were dichotomized into the futile-recanalization group (with a modified Rankin Scale score of 3-6) and the favorable-recanalization group (with a modified Rankin Scale score of 0-2) according to 90-day functional independence. Logistic regression analysis was performed to investigate predictors of futile recanalization. RESULTS Futile recanalization was observed in 200 (49.6%) out of 403 patients. On multivariate analysis, older age (>74 vs. ≤74; odds ratio (OR), 2.41; 95% confidence interval (CI), 1.31-4.44; P=0.005), high baseline National Institutes of Health Stroke Scale score (>21 vs. ≤13; OR, 2.52; 95% CI, 1.21-5.28; P=0.014), delayed puncture to recanalization time (>80 vs. ≤80 min; OR, 2.75; 95% CI, 1.67-4.51; P=0.000), and the use of general anesthesia (OR, 1.90; 95% CI, 1.15-3.14; P=0.012) were positively associated with futile recanalization after mechanical thrombectomy. CONCLUSIONS The incidence of futile recanalization is common following endovascular treatment among Asian patients with anterior circulation occlusion. Advanced age, higher baseline National Institutes of Health Stroke Scale score, delayed puncture to reperfusion, and the use of general anesthesia are associated with lower functional independence 90 days post-treatment despite successful recanalization.
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Affiliation(s)
- Haifeng Xu
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 009, West Road, the South Fourth Ring Road, Fengtai District Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing, China; Beijing Institute for Brain Disorders, Beijing, China.
| | - Baixue Jia
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 009, West Road, the South Fourth Ring Road, Fengtai District Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing, China; Beijing Institute for Brain Disorders, Beijing, China.
| | - Xiaochuan Huo
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 009, West Road, the South Fourth Ring Road, Fengtai District Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing, China; Beijing Institute for Brain Disorders, Beijing, China.
| | - Dapeng Mo
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 009, West Road, the South Fourth Ring Road, Fengtai District Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing, China; Beijing Institute for Brain Disorders, Beijing, China.
| | - Ning Ma
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 009, West Road, the South Fourth Ring Road, Fengtai District Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing, China; Beijing Institute for Brain Disorders, Beijing, China.
| | - Feng Gao
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 009, West Road, the South Fourth Ring Road, Fengtai District Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing, China; Beijing Institute for Brain Disorders, Beijing, China.
| | - Ming Yang
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 009, West Road, the South Fourth Ring Road, Fengtai District Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing, China; Beijing Institute for Brain Disorders, Beijing, China.
| | - Zhongrong Miao
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 009, West Road, the South Fourth Ring Road, Fengtai District Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing, China; Beijing Institute for Brain Disorders, Beijing, China.
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41
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Sharma D, Rasmussen M, Han R, Whalin MK, Davis M, Kofke WA, Venkatraghvan L, Raychev R, Fraser JF. Anesthetic Management of Endovascular Treatment of Acute Ischemic Stroke During COVID-19 Pandemic: Consensus Statement From Society for Neuroscience in Anesthesiology & Critical Care (SNACC): Endorsed by Society of Vascular & Interventional Neurology (SVIN), Society of NeuroInterventional Surgery (SNIS), Neurocritical Care Society (NCS), European Society of Minimally Invasive Neurological Therapy (ESMINT) and American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) Cerebrovascular Section. J Neurosurg Anesthesiol 2020; 32:193-201. [PMID: 32282614 PMCID: PMC7236841 DOI: 10.1097/ana.0000000000000688] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 12/20/2022]
Abstract
The pandemic of coronavirus disease 2019 (COVID-19) has unique implications for the anesthetic management of endovascular therapy for acute ischemic stroke. The Society for Neuroscience in Anesthesiology and Critical Care appointed a task force to provide timely, consensus-based expert recommendations using available evidence for the safe and effective anesthetic management of endovascular therapy for acute ischemic stroke during the COVID-19 pandemic. The goal of this consensus statement is to provide recommendations for anesthetic management considering the following (and they are): (1) optimal neurological outcomes for patients; (2) minimizing the risk for health care professionals, and (3) facilitating judicious use of resources while accounting for existing variability in care. It provides a framework for selecting the optimal anesthetic technique (general anesthesia or monitored anesthesia care) for a given patient and offers suggestions for best practices for anesthesia care during the pandemic. Institutions and health care providers are encouraged to adapt these recommendations to best suit local needs, considering existing practice standards and resource availability to ensure safety of patients and providers.
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Affiliation(s)
- Deepak Sharma
- Departments of Anesthesiology & Pain Medicine
- Neurological Surgery, University of Washington, Seattle, WA
| | - Mads Rasmussen
- Department of Anesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Matthew K. Whalin
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
| | - Melinda Davis
- Department of Anesthesiology, Pain and Perioperative Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - W. Andrew Kofke
- Departments of Anesthesiology and Critical Care
- Neurosurgery, University of Pennsylvania, Philadelphia, PA
| | | | - Radoslav Raychev
- Department of Neurology, University of California Los Angeles, Los Angeles, CA
| | - Justin F. Fraser
- Departments of Neurological Surgery
- Neurology
- Radiology
- Anatomy & Neurobiology, University of Kentucky, Lexington, KY
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42
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Marion JT, Seyedsaadat SM, Pasternak JJ, Rabinstein AA, Kallmes DF, Brinjikji W. Association of local anesthesia versus conscious sedation with functional outcome of acute ischemic stroke patients undergoing embolectomy. Interv Neuroradiol 2020; 26:396-404. [PMID: 32375517 DOI: 10.1177/1591019920923831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Compare functional outcomes of acute ischemic stroke patients undergoing embolectomy with either local anesthesia or conscious sedation. Secondarily, identify differences in hemodynamic parameters and complication rates between groups. MATERIALS AND METHODS Single institution, retrospective review of all acute ischemic stroke patients undergoing embolectomy between January 2014 and July 2018 (n = 185). Patients receiving general anesthesia (n = 27) were excluded. One-hundred and eleven of 158 (70.3%) composed the local anesthesia group, and 47 (29.7%) composed the conscious sedation group. Median age was 71 years (interquartile range 59-79). Seventy-eight (49.4%) were male. The median National Institute of Health stroke scale score was 17.5 (interquartile range 11-21). Hemodynamic, medication, complication, and functional outcome data were collected from the anesthesia protocol and medical records. Good functional outcome was defined as a three-month modified Rankin Scale < 2. A multivariate analysis was performed to estimate the association of anesthesia type on three-month modified Rankin Scale score. RESULTS Three-month modified Rankin Scale score <2 was similar between groups (p = 0.5). Patients receiving conscious sedation were on average younger than patients receiving local anesthesia (p = 0.01). Conscious sedation patients were more likely to receive intravenous thrombolytic prior to embolectomy (p = 0.025). The complication rate and hemodynamic parameters were similar between groups. CONCLUSION Functional outcome of acute ischemic stroke patients undergoing embolectomy appears to be similar for patients receiving local anesthesia and conscious sedation. This similarity may be beneficial to a future study comparing general anesthesia to local anesthesia and conscious sedation. The use of local anesthesia or conscious sedation does not significantly impact hemodynamic status.
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43
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Taqi MA, Suriya SS, Sodhi A, Quadri SA, Farooqui M, Zafar A, Mortazavi MM. Ideal sedation for stroke thrombectomy: a prospective pilot single-center observational study. Neurosurg Focus 2020; 46:E16. [PMID: 30717046 DOI: 10.3171/2018.11.focus18522] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/14/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVESeveral retrospective studies have supported the use of conscious sedation (CS) over general anesthesia (GA) as the preferred methods of sedation for stroke thrombectomy, but a recent randomized controlled trial showed no difference in outcomes after CS or GA. The purpose of the Ideal Sedation for Stroke Thrombectomy (ISST) study was to evaluate the difference in time and outcomes in the reperfusion of anterior circulation in ischemic stroke using GA and monitored anesthesia care (MAC).METHODSThe ISST study was a prospective, open-label registry. A total of 40 patients who underwent mechanical thrombectomy for anterior circulation ischemic stroke were enrolled. Informed consent was obtained from each patient before enrollment. The primary endpoint included the interval between the patient's arrival to the interventional radiology room and reperfusion time. Secondary endpoints were evaluated to estimate the effects on the outcome of patients between the 2 sedation methods.RESULTSOf the 40 patients, 32 received thrombectomy under MAC and 8 patients under GA. The male-to-female ratio was 18:14 in the MAC group and 4:4 in the GA group. The mean time from interventional radiology room arrival to reperfusion in the GA group was 2 times higher than that in the MAC group. Complete reperfusion (TICI grade 3) was achieved in more than 50% of patients in both groups. The mean modified Rankin Scale score at 3 months was < 2 in the MAC group and > 3 in the GA group (p = 0.021).CONCLUSIONSThe findings from the pilot study showed a significantly shorter time interval between IR arrival and reperfusion and better outcomes in patients undergoing reperfusion for ischemic stroke in the anterior circulation using MAC compared with GA.Clinical trial registration no.: NCT03036631 (clinicaltrials.gov).
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Affiliation(s)
- M Asif Taqi
- 1National Skull Base Foundation, Thousand Oaks.,2Los Robles Hospital and Medical Center, Thousand Oaks, California
| | | | - Ajeet Sodhi
- 1National Skull Base Foundation, Thousand Oaks.,2Los Robles Hospital and Medical Center, Thousand Oaks, California
| | | | - Mudassir Farooqui
- 3University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Atif Zafar
- 4University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Martin M Mortazavi
- 1National Skull Base Foundation, Thousand Oaks.,2Los Robles Hospital and Medical Center, Thousand Oaks, California
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Flottmann F, Leischner H, Broocks G, Faizy TD, Aigner A, Deb-Chatterji M, Thomalla G, Krauel J, Issleib M, Fiehler J, Brekenfeld C. Emergency Conversion to General Anesthesia Is a Tolerable Risk in Patients Undergoing Mechanical Thrombectomy. AJNR Am J Neuroradiol 2020; 41:122-127. [PMID: 31806594 DOI: 10.3174/ajnr.a6321] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 10/01/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy for acute ischemic stroke is performed with the patient under local anesthesia, conscious sedation, or general anesthesia. According to recent trials, up to 16% of patients require emergency conversion to general anesthesia during mechanical thrombectomy. This study investigated the procedural and clinical outcomes after emergency conversion in comparison with local anesthesia, conscious sedation, and general anesthesia. MATERIALS AND METHODS This retrospective study included 254 patients undergoing mechanical thrombectomy for acute large-vessel occlusion. The procedure was started with the patient either under local anesthesia, conscious sedation, or general anesthesia. Emergency conversion was defined as induction of general anesthesia during mechanical thrombectomy. The primary outcomes were successful reperfusion (TICI 2b/3) and functional independence (mRS at 90 days, ≤2). RESULTS Twenty-five patients (9.8%) required emergency conversion to general anesthesia. The time from admission to flow restoration was increased under general anesthesia (median, 137 minutes) and emergency conversion (median, 138 minutes) compared with local anesthesia (median 110 minutes). After adjustment for confounders, emergency conversion to general anesthesia and primary general anesthesia had comparable chances of successful reperfusion (OR = 1.28; 95% CI, 0.31-5.25). Patients with emergency conversion had a tendency toward higher chances of functional independence (OR = 4.48; 95% CI, 0.49-40.86) compared with primary general anesthesia, but not compared with local anesthesia (OR = 0.86; 95% CI, 0.14-5.11) and conscious sedation (OR = 1.07; 95% CI, 0.17-6.53). CONCLUSIONS Patients with emergency conversion did not have lower chances of successful reperfusion or functional independence compared those with primary general anesthesia, and time to flow restoration was also similar. We found no evidence supporting the primary induction of general anesthesia in patients at risk for emergency conversion.
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Affiliation(s)
- F Flottmann
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| | - H Leischner
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| | - G Broocks
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| | - T D Faizy
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| | - A Aigner
- Institute of Medical Biometry and Epidemiology (A.A.)
- Institute of Public Health (A.A.), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - G Thomalla
- Departments of Neurology (M.D.-C., G.T.)
| | - J Krauel
- Anaesthesiology (J.K., M.I.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Issleib
- Anaesthesiology (J.K., M.I.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| | - C Brekenfeld
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
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45
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Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic Stroke (CANVAS): Results of the CANVAS Pilot Randomized Controlled Trial. J Neurosurg Anesthesiol 2020; 32:41-47. [DOI: 10.1097/ana.0000000000000567] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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46
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Hindman BJ, Dexter F. Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 2: Integrating and Applying Observational Reports and Randomized Clinical Trials. Anesth Analg 2019; 128:706-717. [PMID: 30883416 DOI: 10.1213/ane.0000000000004045] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The 2018 American Heart Association stroke care guidelines consider endovascular thrombectomy to be the standard of care for patients who have acute ischemic stroke in the anterior circulation when arterial puncture can be made: (1) within 6 h of symptom onset; or (2) within 6-24 h of symptom onset when specific eligibility criteria are satisfied. The aim of this 2-part review is to provide practical perspective on the clinical literature regarding anesthesia care of endovascular thrombectomy patients. In the preceding companion article (part 1), the rationale for rapid workflow and maintenance of blood pressure before reperfusion were reviewed. Also in part 1, the key patient and procedural factors determining endovascular thrombectomy effectiveness were identified. In this article (part 2), the observational literature regarding anesthesia for endovascular thrombectomy is summarized briefly, largely to identify its numerous biases, but also to develop hypotheses regarding sedation versus general anesthesia pertaining to workflow, hemodynamic management, and intra- and post-endovascular thrombectomy adverse events. These hypotheses underlie the conduct and outcome measures of 3 recent randomized clinical trials of sedation versus general anesthesia for endovascular thrombectomy. A meta-analysis of functional outcomes from these 3 trials show, when managed according to trial protocols, sedation and general anesthesia result in outcomes that are not significantly different. Details regarding anesthesia and hemodynamic management from these 3 trials are provided. This article concludes with a pragmatic approach to real-time anesthesia decision-making (sedation versus general anesthesia) and the goals and methods of acute phase anesthesia management of endovascular thrombectomy patients.
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Affiliation(s)
- Bradley J Hindman
- From the Department of Anesthesia, The University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
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47
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Anesthesia practice for endovascular therapy of acute ischemic stroke in Europe. Curr Opin Anaesthesiol 2019; 32:523-530. [PMID: 31045592 DOI: 10.1097/aco.0000000000000746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Anesthetic assistance is often required during endovascular therapy (EVT) of large vessel occlusion in patients with acute ischemic stroke. It is currently debated whether EVT should be performed under general anesthesia or conscious sedation. This review will summarize the recent literature with emphasis on the influence of anesthesia method on neurological outcome. RECENT FINDINGS Recent randomized trials have reported no difference in outcome after EVT performed under either conscious sedation or general anesthesia. This is in contrast to a substantial number of retrospective studies, which found that EVT performed under general anesthesia was associated with a worse neurologic outcome compared with conscious sedation. Anesthetic drugs affect vessel tone and the level of blood pressure may influence outcome. The most favorable choice of anesthetic agents and ventilatory strategy is still debated. SUMMARY The optimal anesthetic practice for EVT remains to be identified. Currently, conscious sedation is often an easy first-line strategy, but general anesthesia can be considered an equal and safe alternative to conscious sedation when there is a carefully administered anesthetic that maintains strict hemodynamic control. Attention to ventilation is advocated. The presence of a specialized neuroanesthesiologist or otherwise dedicated anesthesia personnel is highly recommended.
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48
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Deng C, Campbell D, Diprose W, Eom C, Wang K, Robertson N, Short TG, Brew S, Caldwell J, McGuinness B, Barber PA. A pilot randomised controlled trial of the management of systolic blood pressure during endovascular thrombectomy for acute ischaemic stroke. Anaesthesia 2019; 75:739-746. [DOI: 10.1111/anae.14940] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 01/03/2023]
Affiliation(s)
- C. Deng
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - D. Campbell
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - W. Diprose
- Department of Radiology Auckland City Hospital Auckland New Zealand
| | - C. Eom
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - K. Wang
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - N. Robertson
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - T. G. Short
- Department of Anaesthesia and Peri‐operative Medicine Auckland City Hospital Auckland New Zealand
| | - S. Brew
- Department of Radiology Auckland City Hospital Auckland New Zealand
| | - J. Caldwell
- Department of Radiology Auckland City Hospital Auckland New Zealand
| | - B. McGuinness
- Department of Radiology Auckland City Hospital Auckland New Zealand
| | - P. A. Barber
- Department of Medicine University of Auckland Auckland New Zealand
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Assessment of Anesthesia Practice Patterns for Endovascular Therapy for Acute Ischemic Stroke: A Society for Neuroscience in Anesthesiology and Critical Care (SNACC) Member Survey. J Neurosurg Anesthesiol 2019; 33:343-346. [PMID: 31688332 DOI: 10.1097/ana.0000000000000661] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 10/01/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The choice of general anesthesia (GA) or conscious sedation (CS) may impact neurological outcomes of patients undergoing endovascular therapy (EVT) for acute ischemic stroke (AIS). The aim of this survey was to describe the practice patterns of members of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) for anesthetic management of AIS. METHODS Following institutional review board approval, a 16-question online survey assessing anesthetic management of patients with AIS undergoing EVT was circulated to members of SNACC. RESULTS A total of 76 SNACC members from 52 institutions and 11 countries completed the survey (12.5% response rate). Overall, 33% of institutions reported dedicated neuroanesthesia teams for EVT. Patients treated with GA ranged from 5% to 100% between centers. In total 51% and 49% of centers in the United States reported preferentially providing GA and CS, respectively, compared with 34% and 66%, respectively, in European centers. Reported anesthetic induction agents are propofol (64%), etomidate (4%) and either medication (33%). For maintenance of GA, volatile anesthetic is used more often (54%) than propofol (16%). There was wide variation in medications used for CS. Arterial catheter placement was reported by 75% and 43% of respondents for patients undergoing GA and CS, respectively. Systolic blood pressure >140 mm Hg was targeted by 35.7% of respondents, with others targeting mean arterial pressure within 10%, 20% or 30% of baseline values. Phenylephrine and norepinephrine were the most commonly used vasopressors. CONCLUSIONS There is wide variation in anesthesia technique and hemodynamic management during EVT for AIS, and no consensus on the choice of, or preferred medications for, GA or CS, or target blood pressure and management of hypotension during the procedure.
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Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344-e418. [PMID: 31662037 DOI: 10.1161/str.0000000000000211] [Citation(s) in RCA: 3184] [Impact Index Per Article: 636.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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