Discussion
death, Stroke, pain, rupture, neurological deficits, sudden artery displacement
REGRESSION, STROKE, COMPLICATION, ACUTE ISCHEMIC STROKE, COMPLICATIONS
In the subgroup analysis of DIRECT-MT, no significant difference was observed between GA and non-GA groups on the functional outcome at 90 days, while the early neurological improvement in non-GA group was better than that in GA group in terms of NIHSS score at 24 h and 5–7 days or discharge. Patients in GA group were associated with a significant delay in the workflow time interval but GA was likely to incur fewer severe procedural complications compared with non-GA, although the between-group difference was not significant. The choice of anesthesia patterns was determined by the condition of patients. Non-GA usually is the first choice because of the possible time saving. GA would be performed if the patients cooperated poorly or had high risk of aspiration and troubles in the management of blood pressure and respiration.Our findings were in line with the result of THRACE trial [Despite the similar results of primary outcome between the two treatment arms, the use of general anesthesia showed higher successful recanalization rates in GOLIATH and GASS trials and better functional outcomes at 90 days in GOLIATH [However, the results of subgroup analysis and registry population analysis from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) and the Interventional Management of Stroke (IMS) III trial demonstrated higher rates of death or disability with GA [Overall, the present findings of RCTs plus the meta-analysis indicate a similar clinical benefit between the two approaches. The patients in GA group might have lower ASPECTS scores with more severe neurological deficits and longer time intervals from randomization to perfusion. In this study, the bias of lower ASPECTS and workflow delay in GA group was also observed, which reversely boosts the benefit of non-GA approach. In contrast, severe manipulation complication was a major concern for patients who received mechanical thrombectomy under non-general anesthesia. Patient movement due to decreased consciousness level or pain caused by retrieval of stent retrievers could induce manipulation mistakes, possibly leading to vessel perforation and perforator arteries rupture caused by sudden artery displacement. The findings from HERMES meta-analysis showed there was no significant difference in the rate of vessel perforation between patients who had GA or non-GA [Efficient workflow leads to improved functional outcomes among patients who underwent mechanical thrombectomy [There are several limitations in this subgroup study. First, unbalanced baseline characteristics confound the analysis of clinical outcomes because the patient selection was not randomized for GA. The important prognostic variable of baseline ASPECTS and time from onset to randomization favored the non-GA group. Although multivariable ordinal regression was used to adjust the confounders, the bias was difficult to eliminate. Second, the differences between anesthesia and conscious sedation in non-GA group were not investigated, because local details pertaining to conscious sedation or local anesthesia including agents used and hemodynamic parameters during the MT were not recorded. The in-depth analysis of the efficiency of anesthesia modality was limited. Third, the judgment of the final results was affected by the intention-to-treat principle. A portion of patients who were converted from non-GA to GA during thrombectomy was scored as non-GA group. In addition, anesthesia has been performed if patients receiving catheter angiography, but some might withdraw from thrombectomy because of the operational complication at the beginning of thrombectomy. These patients were all included as intention-to-treat patients.In conclusion, these findings in DIRECT-MT showed no significant difference in functional outcome between GA and non-GA groups for patients who received mechanical thrombectomy. The results were consistent with that from recent RCTs on anesthesia, indicating patients derive similar benefits from general anesthesia. The rate of severe manipulation-related complications tends to be higher in non-GA group while the workflow time interval was significantly delayed in GA group. These findings imply efficient workflow for general anesthesia and strict anesthesia protocol for patient movement for patients with non-GA are warranted to improve clinical outcomes.