General anesthesia trumps sedation for thrombectomy in randomized trial

General anesthesia during endovascular therapy (EVT) for acute ischemic stroke was tied to better outcomes than conscious sedation in a randomized single-center study, contrasting with findings from previous observational trials.

MRI scans taken before thrombectomy and 48 to 72 hours afterward showed infarcts had grown a median 8.2 milliliters with general anesthesia (GA) and 19.4 mL with conscious sedation (CS), although the difference wasn’t statistically significant for the small study of 128 patients published in JAMA Neurology. The subjects—with a mean age of 71.4 who were 51.6 percent male—were all treated within six hours of symptom onset for large vessel occlusions in the anterior circulation.

“At 90 days, improved functional outcomes were seen among patients in the GA group,” wrote lead researcher Claus Z. Simonsen, MD, PhD, with Aarhus University Hospital in Demark, and colleagues. “No clinically meaningful differences in safety endpoints were seen between the 2 arms. These findings support GA as a viable anesthetic approach during EVT.”

The researchers noted previous observational studies suggested CS as the superior approach, but they were likely confounded by selection bias. Patients with increased stroke severity were more likely to undergo GA and therefore more likely to experience worse outcomes.

Two previous randomized trials, they said, were inconclusive, with one giving a slight edge to GA and the other showing no significant difference between the techniques.

In their own trial, Simonsen et al. found successful reperfusion (greater than 50 percent) was achieved in 76.9 percent of GA patients versus 60.3 percent of CS patients. Neurological outcomes—assessed by 24-hour changes in National Institutes of Health Stroke Scale score—favored the GA group but didn’t reach statistical significance.

Finally, at 90 days of follow-up, the GA group showed 91 percent increased odds of progressing to a lower modified Rankin Scale score—with lower scores equaling greater patient independence.

“Contrary to numerous nonrandomized studies that have reported better outcomes with CS, the GOLIATH trial shows signals in favor of GA for multiple end points,” the researchers concluded.

The authors pointed out the operators at their center routinely performed thrombectomy using CS before this trial, making it unlikely the differences in reperfusion could be attributable to operator inexperience.

“All three single-center randomized anesthesia trials found that GA does not lead to worse outcomes,” Simonsen and colleagues wrote. “But it should be emphasized that these studies were performed at institutions with easy access to advanced anesthesia care, which might have contributed to the success of GA use.”

Due to its small sample size, the study may have also been underpowered to detect the primary endpoint of infarct growth, the researchers noted. They plan to perform a meta-analysis to address that problem.