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; SELECT, EXTEND-IA, EXTEND-IA TNK, and EXTEND-IA TNK Part-II Investigators

doi:10.1212/WNL.0000000000201384

Thrombectomy Outcomes With General vs Nongeneral Anesthesia: A Pooled Patient-Level Analysis From the EXTEND-IA Trials and SELECT Study

Neurology. 2023 Jan 17;100(3):e336-e347. doi: 10.1212/WNL.0000000000201384. Epub 2022 Oct 26.

Authors

Amrou Sarraj¹, Gregory W Albers², Peter J Mitchell², Ameer E Hassan², Michael G Abraham², Spiros Blackburn², Gagan Sharma², Nawaf Yassi², Timothy J Kleinig², Darshan G Shah², Teddy Y Wu², Muhammad Shazam Hussain², Wondwoseen G Tekle², Santiago Ortega Gutierrez², Amin Nima Aghaebrahim², Diogo C Haussen², Gabor Toth², Deep Pujara², Ronald F Budzik², William Hicks², Nirav Vora², Randall C Edgell², Sabreena Slavin², Colleen G Lechtenberg², Laith Maali², Abid Qureshi², Lee Rosterman², Mohammad Ammar Abdulrazzak², Tareq AlMaghrabi², Faris Shaker², Osman Mir², Ashish Arora², Sheryl Martin-Schild², Clark W Sitton², Leonid Churilov², Rishi Gupta², Maarten G Lansberg², Raul G Nogueira², James C Grotta², Geoffrey Alan Donnan², Stephen M Davis², Bruce C V Campbell²; SELECT, EXTEND-IA, EXTEND-IA TNK, and EXTEND-IA TNK Part-II Investigators

Collaborators

SELECT, EXTEND-IA, EXTEND-IA TNK, and EXTEND-IA TNK Part-II Investigators:
B C V Campbell, P J Mitchell, S M Davis, B Yan, R J Dowling, N Yassi, T J Oxley, T Y Wu, G Silver, A McDonald, R McCoy, T J Kleinig, R Scroop, H M Dewey, M Simpson, M Brooks, B Coulton, M Krause, T J Harrington, B Steinfort, K Faulder, M Priglinger, S Day, T Phan, W Chong, M Holt, R V Chandra, H Ma, D Young, K Wong, T Wijeratne, H Tu, E Mackay, S Celestino, C F Bladin, P S Loh, A Gilligan, Z Ross, S Coote, T Frost, M W Parsons, F Miteff, C R Levi, T Ang, N Spratt, L Kaauwai, M Badve, H Rice, L de Villiers, P A Barber, B McGuinness, A Hope, M Moriarty, P Bennett, A Wong, A Coulthard, A Lee, J Jannes, D Field, B C V Campbell, P J Mitchell, S M Davis, B Yan, R J Dowling, S Bush, N Yassi, T J Oxley, T Y Wu, D Shah, H Zhao, E Rodrigues, P Salvaris, A McDonald, D Jackson, J Tsoleridis, L Pesavento, T J Kleinig, R Scroop, J Taylor, E Cheong, A Balabanski, M Waters, R Drew, J Cranefield, H M Dewey, C F Bladin, P S Loh, P M Choi, A K Gilligan, S Coote, T Frost, Z Ross, G Thomas, V Thijs, M Simpson, M Brooks, A Brodtmann, F C Ng, B Coulton, D Young, T Wijeratne, H Tu, E Mackey, S Celestino, E Low, P Bailey, H Rice, L de Villiers, A Sabet, S Mishra, B Urbi, F Miteff, M W Parsons, C R Levi, T Ang, N Spratt, C Garcia-Esperon, L Kaauwai, D Shah, H Brown, K Redmond, D Leggett, A A Wong, C Muller, A Coulthard, J Clouston, K Mitchell, K Mahady, H Ma, T Phan, W Chong, M Holt, R V Chandra, L-A Slater, K Wong, D Field, W Vallat, V Maxwell, M Krause, T J Harrington, B Steinfort, K Faulder, S Day, T Y Wu, J N Fink, W Collecutt, J Eagle, P A Barber, B McGuinness, A Hope, M Moriarty, L Zhao, G Cloud, A Madan, A Moore, T J Kleinig, R Scroop, J Taylor, C Kurunawai, E Cheong, A Balabanski, M Waters, J Harvey, L Cagi, N Chia, A Khoo, R Drew, J Cranefield, B C V Campbell, P J Mitchell, S M Davis, G A Donnan, M W Parsons, N Yassi, B Yan, R J Dowling, S Bush, T J Oxley, T Y Wu, D Shah, H Zhao, C Williams, E Rodrigues, P Salvaris, F Alemseged, F C Ng, A Balabanski, A Dos Santos, J-L Ng, S Coote, C Beltrame, E Mackey, K Lagma, A McDonald, D Jackson, J Tsoleridis, L Pesavento, V Thijs, M Simpson, M Brooks, H Asadi, A Jhamb, A Brodtmann, F C Ng, A Warwick, B Coulton, D Young, D Shah, H Brown, K Redmond, D Leggett, J Whitley, C Bendall, T Wijeratne, H Tu, E Mackey, S Celestino, E Low, P Bailey, H Rice, L de Villiers, A Sabet, S Mishra, B Urbi, H M Dewey, P M C Choi, T Frost, J Chen, S K Chen, M Y Tang, K Nowak, R Martins, C Senanayake, C H Yam, D Barber, F M Bridge, J Z W Wong, G Thomas, J Liu, N Pachani, R Lee, T Kraemer, R Sahathevan, C Hair, M Krause, T J Harrington, B Steinfort, K Faulder, D Cordato, A J McDougall, C Cappelen-Smith, J Wenderoth, A Cheung, N Manning, D Field, A Moey, M J Waters, V Maxwell, H Ma, T Phan, S Singhal, B Clissold, J Ly, W Chong, R V Chandra, L-A Slater, H Asadi, B O'Brien, J Evans, D Alchin, B Clissold, P Talman, C Shaw, A Malhotra, R Makonahalli, F Miteff, N Spratt, C Garcia-Esperon, L Kaauwai, A Clissold, P Groot, G Cloud, A Madan, C Chung, A Moore, L Bolitho, R Krones, N Bilkhu, H Haines, F Eversheim, L Bonavia, A Bhattacharya, R D Smith, E Ray, T Coupland, A Wright, A Mamun, J Worthington, T Ang, S Winters, D Brunacci, K Tastula, A A Wong, C Muller, A Coulthard, J Clouston, K Mitchell, K Mahady, F O'Rourke, Y Liu, Y-M Kuang, A Wu, Karen Smith, Michael Stephenson, Emily Andrew, Christopher Bladin, Matthew Lightermoet, Matthew Lee-Archer, Felix C Ng, Marion Simpson, T Y Wu, J N Fink, J Beharry, W Collecutt, A Laing, M Krauss, J Eagle, G Uys, L Arthurson, K Mandeleson, A Van Berkel, R Grimley, W Skoien, N Mahant, P A Barber, B McGuinness, A Hope, S Brew, M Moriarty, L Zhao, Amrou Sarraj, Peng R Chen, Spiros Blackburn, Mark Dannenbaum, Diogo Haussen, Raul G Nogueira, Michael Frankel, Indrani Acosta, Evan Allen, Frank Hellinger, Randall Edgell, Michael Abraham, Ronald F Budzik Jr, William Hicks, Nirav Vora, Jennifer Mejilla, Gregory W Albers, Maarten Lansberg, Ameer E Hassan, Rishi Gupta

Affiliations

¹ 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. Amrou.Sarraj@uhhospitals.org.
² 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.

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), p _interaction: 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 (p _interaction: 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).

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Anesthesia, General* / adverse effects
Humans
Prospective Studies
Randomized Controlled Trials as Topic
Thrombectomy* / methods
Treatment Outcome

Associated data

ClinicalTrials.gov/NCT01492725
ClinicalTrials.gov/NCT02388061
ClinicalTrials.gov/NCT03340493
ClinicalTrials.gov/NCT02446587