Abstract
Background:
Achievement of successful reperfusion during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) may affected by patient motion, especially in more difficult to access, technically challenging targets, such as tandem and distal occlusions. General anesthesia (GA) may be particularly beneficial as compared to conscious sedation (CS) in such patients.
Methods:
We evaluated target occlusion subtypes in the GOLIATH randomized trial comparing GA and CS. Patients were divided in 2 groups based on target arterial occlusion: 1) single, proximal occlusion (ICA T/M1), and 2) tandem or distal (M2) occlusion. Technical success was defined as substantial reperfusion (TICI 2B/3). Clinical outcome measures at 90 days included disability level (mRS ordinal), functional independence (mRS 0-2), and mortality. Multivariable analysis adjusted for age, baseline NIHSS, baseline ischemic core volume, and IV TPA was conducted in each group to assess the impact on technical and clinical outcome. Interaction test for heterogeneity was conducted to assess the difference in outcomes across the subrgoups.
Results:
Among 128 analyzed patients, 80 (62.5%) had single, proximal occlusions and 48 (37.5%) had tandem (22.7%) or distal (14.8%). The absolute difference in substantial reperfusion was higher for both tandem occlusion (83.3% vs 36.4%) and distal occlusion (75% vs 57.1%) than for single, proximal occlusion (74.3% vs 66.7%). The combined distal and tandem occlusion group showed magnified reperfusion success with GA vs CS (80.0% vs 44.4%) compared with the single, proximal occlusion group, (p=0.048, interaction test for heterogeneity). The single and proximal occlusion group showed improved 3m functional independence with GA vs PS (p=0.030), although the heterogeneity between groups was not significant (proximal and single: 71.4% vs 44.4%; tandem or distal: 63.3% vs 72.2%, heterogeneity p=0.12). There was no heterogeneity in the effect of method of sedation on mortality across analyzed groups.
Conclusions:
Achievement of substantial reperfusion during endovascular thrombectomy may differentially be aided by general anesthesia in patients with technically more challenging distal and tandem occlusions