Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

被引：206

作者：

Campbell, Bruce C. V. ^{[1
]}

van Zwam, Wim H. ^{[4
]}

Goyal, Mayank ^{[6
]}

Menon, Bijoy K. ^{[6
]}

Dippel, Diederik W. J. ^{[7
]}

Demchuk, Andrew M. ^{[6
]}

Bracard, Serge ^{[10
]}

White, Philip ^{[13
]}

Davalos, Antoni ^{[14
]}

Majoie, Charles B. L. M. ^{[15
]}

van der Lugt, Aad ^{[8
]}

Ford, Gary A. ^{[17
,18
]}

Perez de la Ossa, Natalia ^{[14
]}

Kelly, Michael ^{[19
]}

Bourcier, Romain ^{[20
,21
]}

Donnan, Geoffrey A. ^{[3
]}

Roos, Yvo B. W. E. M. ^{[16
]}

Bang, Oh Young ^{[22
]}

Nogueira, Raul G. ^{[23
]}

Devlin, Thomas G. ^{[24
]}

van den Berg, Lucie A. ^{[16
]}

Clarencon, Frederic ^{[25
,26
]}

Burns, Paul ^{[27
]}

Carpenter, Jeffrey ^{[28
]}

Berkhemer, Olvert A. ^{[7
,8
,9
,15
]}

Yavagal, Dileep R. ^{[29
]}

Pereira, Vitor Mendes ^{[30
,31
,32
,33
]}

Ducrocq, Xavier ^{[34
]}

Dixit, Anand ^{[13
]}

Quesada, Helena ^{[35
]}

Epstein, Jonathan ^{[11
]}

Davis, Stephen M. ^{[1
]}

Jansen, Olav ^{[36
]}

Rubiera, Marta ^{[37
]}

Urra, Xabier ^{[38
]}

Micard, Emilien ^{[12
]}

Lingsma, Hester F. ^{[9
]}

Naggara, Olivier ^{[39
,40
]}

Brown, Scott ^{[41
]}

Guillemin, Francis ^{[11
]}

Muir, Keith W. ^{[42
]}

van Oostenbrugge, Robert J. ^{[5
]}

Saver, Jeffrey L. ^{[43
,44
]}

Jovin, Tudor G. ^{[45
]}

Hill, Michael D. ^{[6
]}

Mitchell, Peter J. ^{[2
]}

机构：

[1] Melbourne Brain Ctr, Dept Med & Neurol, Parkville, Vic, Australia

[2] Royal Melbourne Hosp, Dept Radiol, Parkville, Vic, Australia

[3] Univ Melbourne, Florey Inst Neurosci & Mental Hlth, Parkville, Vic, Australia

[4] Maastricht Univ, Med Ctr, Dept Radiol, Maastricht, Netherlands

[5] Maastricht Univ, Med Ctr, Dept Neurol, Maastricht, Netherlands

[6] Univ Calgary, Foothills Hosp, Dept Clin Neurosci, Hotchkiss Brain Inst,Cumming Sch Med, Calgary, AB, Canada

[7] Univ Med Ctr, Erasmus MC, Dept Neurol, Rotterdam, Netherlands

[8] Univ Med Ctr, Erasmus MC, Dept Radiol, Rotterdam, Netherlands

[9] Univ Med Ctr, Erasmus MC, Dept Publ Hlth, Rotterdam, Netherlands

[10] Univ Lorraine, INSERM, U947, Dept Diagnost & Intervent Neuroradiol, Nancy, France

[11] Univ Lorraine, INSERM 1433, Clin Invest Ctr, Clin Epidemiol, Nancy, France

[12] Univ Lorraine, INSERM 1433, Clin Invest Ctr, Innovat Technol, Nancy, France

[13] Newcastle Univ, Inst Neurosci, Newcastle Upon Tyne, Tyne & Wear, England

[14] Univ Autonoma Barcelona, Dept Neurosci, Hosp Germans Trias & Pujol, Barcelona, Spain

[15] Acad Med Ctr, Dept Radiol, Amsterdam, Netherlands

[16] Acad Med Ctr, Dept Neurol, Amsterdam, Netherlands

[17] Univ Oxford, Div Med Sci, Oxford, England

[18] Oxford Univ Hosp NHS Fdn Trust, Oxford, England

[19] Univ Saskatchewan, Dept Med Imaging, Saskatoon, SK, Canada

[20] Univ Nantes, Dept Neuroradiol, Nantes, France

[21] Univ Hosp Nantes, Nantes, France

[22] Sungkyunkwan Univ, Dept Neurol, Samsung Med Ctr, Sch Med, Seoul, South Korea

[23] Emory Univ, Sch Med, Dept Neurol, Marcus Stroke & Neurosci Ctr,Grady Mem Hosp, Atlanta, GA 30322 USA

[24] Univ Tennessee, Dept Neurol, Coll Med, Chattanooga, TN USA

[25] Hop La Pitie Salpetriere, Dept Neuroradiol, Paris, France

[26] Paris Pierre & Marie Curie Univ, Paris, France

[27] Royal Victoria Hosp, Dept Neuroradiol, Belfast, Antrim, North Ireland

[28] West Virginia Univ Hosp, Dept Radiol, Morgantown, WV USA

[29] Univ Miami, Miller Sch Med, Dept Neurol & Neurosurg, Jackson Mem Hosp, Miami, FL 33136 USA

[30] Univ Toronto, Univ Hlth Network, Toronto Western Hosp, Div Neuroradiol,Dept Med Imaging, Toronto, ON, Canada

[31] Univ Toronto, Univ Hlth Network, Toronto Western Hosp, Div Neuroradiol,Dept Surg, Toronto, ON, Canada

[32] Univ Toronto, Univ Hlth Network, Toronto Western Hosp, Div Neurosurg,Dept Med Imaging, Toronto, ON, Canada

[33] Univ Toronto, Univ Hlth Network, Toronto Western Hosp, Div Neurosurg,Dept Surg, Toronto, ON, Canada

[34] CHR Mercy, Dept Neurol, Metz, France

[35] Hosp Bellvitge Princeps Espanya, Stroke Unit, Barcelona, Spain

[36] Univ Klinikum Kiel, Inst Neuroradiol, Kiel, Germany

[37] Hosp Valle De Hebron, Stroke Unit, Barcelona, Spain

[38] Hosp Clin Barcelona, Stroke Unit, Barcelona, Spain

[39] St Anne Hosp, Dept Neuroradiol, Paris, France

[40] Paris Descartes Univ, INSERM, U894, IMABRAIN,Neurosci & Psychiat Ctr, Paris, France

[41] Altair Biostat, St Louis Pk, MN USA

[42] Univ Glasgow, Queen Elizabeth Univ Hosp, Inst Neurosci & Psychol, Glasgow, Lanark, Scotland

[43] Univ Calif Los Angeles, David Geffen Sch Med, Dept Neurol, Los Angeles, CA 90095 USA

[44] Univ Calif Los Angeles, David Geffen Sch Med, Comprehens Stroke Ctr, Los Angeles, CA 90095 USA

[45] Univ Pittsburgh, Dept Neurol, Med Ctr, Stroke Inst, Pittsburgh, PA 15260 USA

来源：

LANCET NEUROLOGY | 2018年 / 17卷 / 01期

关键词：

THERAPY; TRIAL; MR;

D O I：

10.1016/S1474-4422(17)30407-6

中图分类号：

R74 [神经病学与精神病学];

学科分类号：

摘要：

Background General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1.52, 95% CI 1.09-2.11, p=0.014) and in those who did not have GA (adjusted cOR 2.33, 95% CI 1.75-3.10, p<0.0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1.53, 95% CI 1.14-2.04, p=0.0044). The risk of bias and variability between studies was assessed to be low. Interpretation Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons.

引用

页码：47 / 53

页数：7

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