Does General Anesthesia Compared With Conscious Sedation Result in Better Outcomes in Acute Stroke Patients Undergoing Endovascular Therapy?

Background: The degree of variability in the rate of early DWI expansion has not been well characterized. We hypothesized that Target Mismatch patients with slowly expanding DWI lesions have more penumbral salvage and better clinical outcomes following endovascular reperfusion than Target Mismatch patients with rapidly expanding DWI lesions. Methods: This substudy of DEFUSE 2 included all patients with a clearly established time of symptom onset. The initial DWI growth rate was determined from the baseline scan by assuming a volume 0 ml just prior to symptom onset. Target Mismatch patients who achieved reperfusion (>50% reduction in PWI after endovascular therapy), were categorized into tertiles according to their initial DWI growth rates. For each tertile, penumbral salvage (comparison of final volume to the volume of PWI (Tmax > 6 sec)/ DWI mismatch prior to endovascular therapy), favorable clinical response, and good functional outcome (see figure for definitions) were calculated. We also compared the growth rate in patients with the Target mismatch vs. Malignant Profile. Results: 64 patients were eligible for this study. Target mismatch patients (n=44) had initial growth rates (range 0 to 43 ml/hr, median of 3 ml/hr) that were significantly less than the growth rates in Malignant profile (n=7) patients (12 to 92 ml/hr, median 39 ml/hr; p < 0.001). In Target mismatch patients who achieved reperfusion (n=30), slower early DWI growth rates were associated with better clinical outcomes (p<0.05) and a trend toward more penumbral salvage (n=27, p=0.137). Conclusions: The growth rate of early DWI lesions in acute stroke patients is highly variable; Malignant profile patients have higher growth rates than other MRI profiles. Among Target Mismatch patients, a slower rate of DWI growth is associated with a greater degree of penumbral salvage and improved clinical outcomes following endovascular reperfusion.

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Different Levels of Ventilation Are a Plausible Explanation for Different Outcomes of Acute Stroke Patients Undergoing Endovascular Therapy

Anesthesiology ◽

10.1097/aln.0b013e318262567a ◽

2012 ◽

Vol 117 (3) ◽

pp. 683-683

Author(s):

E. Lynne Williams

Keyword(s):

Acute Stroke ◽

Endovascular Therapy ◽

Stroke Patients ◽

Different Levels

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Abstract W P11: A Clinical Scale to Predict Futile Arterial Recanalization in Acute Stroke Patients with Anterior Circulation Arterial Occlusion Treated with Endovascular Therapies.

Stroke ◽

10.1161/str.45.suppl_1.wp11 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Natalia Perez de la Ossa ◽

Maria Hernández-Pérez ◽

Monica Millán ◽

Meritxell Gomis ◽

Elena López-Cancio ◽

...

Keyword(s):

Acute Stroke ◽

Scale Score ◽

Endovascular Therapy ◽

Univariate Analysis ◽

Arterial Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

History Of ◽

Stent Retrievers ◽

Arterial Recanalization

Introduction: Futile arterial recanalization (FAR), considered as a lack of functional recovery despite complete recanalization, is observed in up to 30-50% of acute stroke patients treated with endovascular therapy. We aimed to develop a prognostic scale based on baseline clinical and radiological factors to predict FAR. Methods: Prospective analysis of consecutive stroke patients with anterior circulation occlusion treated with endovascular therapy (97% mechanical thrombectomy with stent-retrievers). Complete recanalization was considered as a TICI 2b-3. FAR was defined as a modified Rankin scale >2 at 90 days in patients with complete recanalization. Baseline factors associated with FAR were detected on univariate analysis and were used to compose the predictive scale. Results: From a total of 229 patients with anterior arterial occlusion, 166 (72.5%) achieved complete recanalization. FAR was observed in 80/166 (48.2%). Factors significantly associated with FAR were included to compose the predictive scale as follow: Age (scoring 0 if ≤70 and 1 if >70 years old), history of diabetes mellitus (0 if absent, 1 if present), history of hypertension (0 if absent, 1 if present), NIHSS (1 if NIHSS ≤10, 2 if NIHSS 10-19, 3 if NIHSS>19), ASPECTS (1 if ASPECTS 9-10, 2 if ASPECTS 7-8, 3 if ASPECTS<7) and i.v tPA use (0 if yes, 1 if not). The higher the scale score, the higher the risk of FAR (Figure). The scale showed a good predictive value of FAR (c-statistics 0.71). A scale score <5 was associated with a low rate of FAR (25%) whereas a score >7 increased FAR up to 86%. Conclusion: We developed a simple scale that can easily predict futile arterial recanalization (FAR) in stroke patients with large arterial occlusion treated with endovascular therapies. A larger validation study is necessary to confirm the utility of this predictive scale.

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Abstract 184: Drivers of Costs Associated With Reperfusion Therapy in Acute Stroke: The IMS III Trial

Stroke ◽

10.1161/str.45.suppl_1.184 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Kit N Simpson ◽

Annie N Simpson ◽

Patrick D Mauldin ◽

Michael D Hill ◽

Sharon D Yeatts ◽

...

Keyword(s):

Acute Stroke ◽

General Anesthesia ◽

Endovascular Therapy ◽

Stroke Care ◽

Reperfusion Therapy ◽

Hospital Charges ◽

Acute Stroke Care ◽

Initial Hospital ◽

Initial Hospitalization ◽

Mean Cost

Importance: The annual costs of stroke to the nation have been estimated to be over $38 billion, with nearly $22 billion attributed to direct medical costs. Objective: To understand cost drivers during the initial hospitalization for acute ischemic stroke subjects in the IMS III Trial. Design, Setting and Participants: Prospective cost analysis of subjects from U.S. centers treated with IV t-PA alone or IV t-PA followed by endovascular therapy in the IMS III trial. Cost of initial hospital admission was estimated from the actual hospital charges on UB04 billing forms provided by the treating hospitals. Cost profiles of the IMS III treatment groups were compared to profiles of a sample of US patients from the HCUP National Inpatient Sample (NIS) for 2010. Interventions: IV t-PA alone as compared to IV t-PA followed by endovascular therapy. Main Outcome Measure: Costs of hospitalization for acute stroke subjects. Results: The adjusted cost of a stroke admission in the study was $35,130 for subjects treated with endovascular therapy following IV t-PA and $25,630 for subjects treated with IV t-PA alone (p<0.0001). The higher cost in the endovascular therapy following IV t-PA treatment arm was largely explained by the costs of the devices. Significant factors related to costs included treatment group (higher costs with endovascular therapy), baseline NIH Stroke Scale (higher costs with higher severity), time from stroke onset to IV t-PA (lower costs with earlier treatment), age (higher costs with older age), stroke location (higher cost with right hemispheric location) and comorbid diabetes (higher costs with diabetes). The mean cost for subjects who had routine use of general anesthesia as part of endovascular therapy was $46,444 as compared to $30,350 for those who did not have general anesthesia. The costs of embolectomy for IMS III subjects and patients from the NIS cohort exceeded the Medicare DRG payment in more than 75% of hospitalized patients. Conclusions and Relevance: Changing the processes of acute stroke care, such as minimizing the time to start of IV t-PA and decreasing the use of routine general anesthesia, may improve the cost-effectiveness of medical and endovascular therapy for acute stroke.

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Abstract TP38: Re-Occlusion During Endovascular Therapy for Acute Stroke Patients With Large Vessel Occlusion

Stroke ◽

10.1161/str.50.suppl_1.tp38 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Qing Hao ◽

Jacob Morey ◽

Xiangnan Zhang ◽

Emily Chapman ◽

Reade DeLeacy ◽

...

Keyword(s):

Acute Stroke ◽

Endovascular Therapy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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General Anesthesia may have Similar Outcomes with Conscious Sedation in Thrombectomy Patients with Acute Ischemic Stroke: A Real-World Registry in China

European Neurology ◽

10.1159/000490901 ◽

2018 ◽

Vol 80 (1-2) ◽

pp. 7-13 ◽

Cited By ~ 4

Author(s):

Wanying Shan ◽

Dong Yang ◽

Huaiming Wang ◽

Liang Xu ◽

Meng Zhang ◽

...

Keyword(s):

Propensity Score ◽

Endovascular Treatment ◽

General Anesthesia ◽

Real World ◽

Conscious Sedation ◽

Propensity Score Analysis ◽

Stroke Patients ◽

Anterior Circulation ◽

Score Analysis ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose: Clinical trials showed that anesthesia may not influence the functional outcome in stroke patients with endovascular therapy; however, data are lacking in China. Using real-world registry data, our study aims to compare the effects of general anesthesia or conscious sedation on functional outcomes in stroke patients treated with thrombectomy in China. Methods: Consecutive patients with acute anterior circulation stroke receiving thrombectomy in 21 stroke centers between January 2014 and June 2016 were included in this study. The propensity score analysis with 1: 1 ratio was used to match the baseline variables between patients with general anesthesia and the conscious sedation. The 90-day modified Rankin Scale (mRS), symptomatic intracranial hemorrhage (sICH), and death were compared between groups. Results: Of the 698 patients undergoing endovascular treatment, 138 were treated with general anesthesia and 560 with conscious sedation. After propensity score matching, 114 general anesthesia and 114 conscious sedation patients were matched. The proportions of patients with 90-day mRS 0–2 were not significantly different between general anesthesia and conscious sedation groups (41.2% [47/114] vs. 46.5% [53/114], p = 0.470), nor were the rates of sICH (21.9% [25/114] vs. 12.3% [14/114], p = 0.072) and 90-day mortality (31.6% [36/114] vs. 21.9% [25/114], p = 0.145). Conclusion: Anesthesia patterns may have no significant impacts on clinical outcomes in patients with acute anterior circulation occlusion stroke undergoing endovascular treatment in the real-world practice in China.

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