Monitored Anesthesia Care vs Intubation for Vertebrobasilar Stroke Endovascular Therapy

Abstract

Importance  No consensus regarding the ideal sedation treatment for stroke endovascular therapy has been reached, and practices remain largely based on local protocols and clinician preferences. Most studies have focused on anterior circulation strokes; therefore, little is known regarding the optimal anesthesia type for vertebrobasilar occlusion strokes.

Objective  To compare clinical and angiographic outcomes between monitored anesthesia care (MAC) and general anesthesia (GA) in patients presenting with vertebrobasilar occlusion strokes.

Design, Setting, and Participants  Retrospective, matched, case-control study of consecutive vertebrobasilar occlusion strokes treated with endovascular therapy at 2 academic institutions. The study took place between September 2005 and September 2015 at University of Pittsburgh Medical Center Stroke Institute, Pittsburgh, Pennsylvania, and between September 2010 and September 2015 at the Marcus Stroke and Neuroscience Center at Grady Memorial Hospital, Atlanta, Georgia. Patients requiring emergent intubation prior to endovascular therapy were excluded. The remaining patients were categorized into (1) MAC and (2) elective intubation for the procedure (elective GA). Patients who converted from MAC to GA during the procedure were included in the MAC group. The 2 groups were matched for age, baseline National Institutes of Health Stroke Scale score, and glucose levels. Baseline characteristics and outcomes were compared.

Main Outcomes and Measures  The primary outcome measure was the shift in the degree of disability among the 2 groups as measured by the modified Rankin scale at 90 days.

Results  A total of 215 patients underwent endovascular therapy for vertebrobasilar occlusion strokes during the study period. Thirty-nine patients were excluded owing to emergent pre–endovascular therapy intubation. Sixty-three patients had MAC (36%) and 113 patients had GA (64%). The conversion rate from MAC to GA was 13% (n = 8). After matching, 61 pairs of patients (n = 122) underwent primary analysis. The 2 groups were well balanced in terms of baseline characteristics. Median age was 69 years (interquartile range, 60-75 years) in the MAC group vs 67 years (interquartile range, 55.5-78.5 years) in the GA group (P = .83). Fifty-four percent of the patients in the MAC group were men vs 41% in the GA group (P = .44). When compared with the elective GA group, patients who underwent the procedure with MAC had similar rates of successful reperfusion, good clinical outcomes, hemorrhagic complications, and mortality. The modality of anesthesia was not associated with any significant changes in the modified Rankin scale score distribution (MAC: OR, 1.52; 95% CI, 0.80-2.90; P = .19).

Conclusions and Relevance  In endovascular therapy for acute posterior circulation stroke, MAC is feasible and appears to be as safe and effective as GA. Future clinical trials are warranted to confirm our findings.

JAMA Neurology 2017