Selection of patients and anesthetic types for endovascular treatment in acute ischemic stroke: A meta-analysis of randomized controlled trials

Abstract

Background and Purpose Recent randomized controlled trials have demonstrated consistent effectiveness of endovascular treatment (EVT) for acute ischemic stroke, leading to update on stroke management guidelines.We conducted this meta-analysis to assess the efficacy and safety of EVT overall and in subgroups stratified by age, baseline stroke severity, brain imaging feature, and anesthetic type. Methods Published randomized controlled trials comparing EVT and standard medical care alone were evaluated. The measured outcomes were 90-day functional independence (modified Rankin Scale ≤2), all-cause mortality, and symptomatic intracranial hemorrhage. Results Nine trials enrolling 2476 patients were included (1338 EVT, 1138 standard medical care alone). For patients with large vessel occlusions confirmed by noninvasive vessel imaging, EVT yielded improved functional outcome (pooled odds ratio [OR], 2.02; 95% confidence interval [CI], 1.64-2.50), lower mortality (OR, 0.75; 95% CI, 0.58-0.97), and similar symptomatic intracranial hemorrhage rate (OR, 1.12; 95% CI, 0.72-1.76) compared with standard medical care. A higher proportion of functional independence was seen in patients with terminus intracranial artery occlusion (±M1) (OR, 3.16; 95% CI, 1.64-6.06), baseline Alberta Stroke Program Early CT score of 8-10 (OR, 2.11; 95% CI, 1.25-3.57) and age ≤70 years (OR, 3.01; 95% CI, 1.73-5.24). EVT performed under conscious sedation had better functional outcomes (OR, 2.08; 95% CI, 1.47-2.96) without increased risk of symptomatic intracranial hemorrhage or short-term mortality compared with general anesthesia. Conclusions Vessel-imaging proven large vessel occlusion, a favorable scan, and younger age are useful predictors to identify anterior circulation stroke patients who may benefit from EVT. Conscious sedation is feasible and safe in EVT based on available data. However, firm conclusion on the choice of anesthetic types should be drawn from more appropriate randomized controlled trials.