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January 17, 2023; 100 (3) Research Article

Thrombectomy Outcomes With General vs Nongeneral Anesthesia

A Pooled Patient-Level Analysis From the EXTEND-IA Trials and SELECT Study

View ORCID ProfileAmrou Sarraj, Gregory W. Albers, Peter J. Mitchell, Ameer E. Hassan, Michael G. Abraham, Spiros Blackburn, Gagan Sharma, Nawaf Yassi, Timothy J. Kleinig, Darshan G. Shah, Teddy Y. Wu, Muhammad Shazam Hussain, View ORCID ProfileWondwoseen G. Tekle, Santiago Ortega Gutierrez, Amin Nima Aghaebrahim, Diogo C. Haussen, Gabor Toth, Deep Pujara, Ronald F. Budzik, William Hicks, Nirav Vora, Randall C. Edgell, Sabreena Slavin, Colleen G. Lechtenberg, Laith Maali, Abid Qureshi, Lee Rosterman, Mohammad Ammar Abdulrazzak, Tareq AlMaghrabi, View ORCID ProfileFaris Shaker, View ORCID ProfileOsman Mir, View ORCID ProfileAshish Arora, Sheryl Martin-Schild, Clark W. Sitton, Leonid Churilov, Rishi Gupta, View ORCID ProfileMaarten G. Lansberg, Raul G. Nogueira, James C. Grotta, Geoffrey Alan Donnan, Stephen M. Davis, View ORCID ProfileBruce C. V. Campbell, on behalf of the SELECT, EXTEND-IA, EXTEND-IA TNK, and EXTEND-IA TNK Part-II Investigators
First published October 26, 2022, DOI: https://doi.org/10.1212/WNL.0000000000201384
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.
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Gregory W. Albers
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Peter J. Mitchell
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Ameer E. Hassan
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Michael G. Abraham
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Spiros Blackburn
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Gagan Sharma
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Nawaf Yassi
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Timothy J. Kleinig
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Darshan G. Shah
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Teddy Y. Wu
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Muhammad Shazam Hussain
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Wondwoseen G. Tekle
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Santiago Ortega Gutierrez
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Amin Nima Aghaebrahim
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Deep Pujara
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Ronald F. Budzik
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Nirav Vora
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Randall C. Edgell
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Sabreena Slavin
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Colleen G. Lechtenberg
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Laith Maali
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Abid Qureshi
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Lee Rosterman
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Mohammad Ammar Abdulrazzak
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Tareq AlMaghrabi
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Faris Shaker
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Osman Mir
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Ashish Arora
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Sheryl Martin-Schild
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Clark W. Sitton
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Leonid Churilov
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Rishi Gupta
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Maarten G. Lansberg
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Raul G. Nogueira
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James C. Grotta
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Geoffrey Alan Donnan
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Stephen M. Davis
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Bruce C. V. Campbell
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Citation
Thrombectomy Outcomes With General vs Nongeneral Anesthesia
A Pooled Patient-Level Analysis From the EXTEND-IA Trials and SELECT Study
Amrou Sarraj, Gregory W. Albers, Peter J. Mitchell, Ameer E. Hassan, Michael G. Abraham, Spiros Blackburn, Gagan Sharma, Nawaf Yassi, Timothy J. Kleinig, Darshan G. Shah, Teddy Y. Wu, Muhammad Shazam Hussain, Wondwoseen G. Tekle, Santiago Ortega Gutierrez, Amin Nima Aghaebrahim, Diogo C. Haussen, Gabor Toth, Deep Pujara, Ronald F. Budzik, William Hicks, Nirav Vora, Randall C. Edgell, Sabreena Slavin, Colleen G. Lechtenberg, Laith Maali, Abid Qureshi, Lee Rosterman, Mohammad Ammar Abdulrazzak, Tareq AlMaghrabi, Faris Shaker, Osman Mir, Ashish Arora, Sheryl Martin-Schild, Clark W. Sitton, Leonid Churilov, Rishi Gupta, Maarten G. Lansberg, Raul G. Nogueira, James C. Grotta, Geoffrey Alan Donnan, Stephen M. Davis, Bruce C. V. Campbell, on behalf of the SELECT, EXTEND-IA, EXTEND-IA TNK, and EXTEND-IA TNK Part-II Investigators
Neurology Jan 2023, 100 (3) e336-e347; DOI: 10.1212/WNL.0000000000201384

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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), pinteraction: 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 (pinteraction: 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).

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • SELECT, EXTEND-IA, EXTEND-IA TNK, and EXTEND-IA TNK Part-II coinvestigators are listed at links.lww.com/WNL/C448.

  • Submitted and externally peer reviewed. The handling editor was José Merino, MD, MPhil, FAAN.

  • Class of Evidence: NPub.org/coe

  • Infographic NPub.org/ig1003

  • Received February 24, 2022.
  • Accepted in final form August 24, 2022.
  • © 2022 American Academy of Neurology
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