Outcomes of Anesthesia Selection in Endovascular Treatment of Acute Ischemic Stroke

Abstract

Background:
The association between anesthesia type and outcomes in patients with acute ischemic stroke undergoing endovascular treatment (EVT) remains a subject of ongoing debate.

Methods:
This prospective nonrandomized controlled trial included 149 consecutive patients with acute anterior circulation stroke who underwent EVT. The primary outcome was functional independence assessed by the modified Rankin Scale (mRS) after 3 months.

Results:
A total of 105 (70.5%) and 44 (29.5%) patients undergoing EVT who received conscious sedation (CS) and general anesthesia (GA), respectively. The patients who received GA had similar demographics and basic National Institute of Health Stroke Scale scores (17 vs. 16, P>0.05) as the patients who received CS. The recanalization time (304 vs. 311 min, P=0.940) and the recanalization rate (86.4% vs. 84.1%, P=0.170) did not differ between the patients receiving the different types of anesthesia. The National Institute of Health Stroke Scale at 24 hours was lower in the patients who received CS than in those who received GA (β=-2.26, 95% confidence interval, -5.30 to 0.79). The independence (modified Rankin Scale score 0 to 2) at 3 months was equal between patients who received GA and those who received CS (odds ratio=0.73, 95% confidence interval, 0.32-1.68). The mortality and the morbidity rates did not differ.

Conclusions:
The data indicated that the selection of GA or CS during EVT had no impact on the independent outcomes of patients with anterior circulation occlusion.

Full text

Outcomes of Anesthesia Selection in Endovascular
Treatment of Acute Ischemic Stroke
Yuming Peng, MD, PhD,* Youxuan Wu, MD,* Xiaochuan Huo, MD, PhD,†Peng Wu, PhD,‡
Yang Zhou, MD,* Jiaxin Li, MD,* Fa Liang, MD,* Xiaoyuan Liu, MD, PhD,*
Yuesong Pan, PhD,‡Zhongrong Miao, MD, PhD,†Ruquan Han, MD, PhD,*
and on behalf of Endovascular Therapy for Acute Ischemic Stroke Trial (EAST) group
Background: The association between anesthesia type and out-
comes in patients with acute ischemic stroke undergoing endo-
vascular treatment (EVT) remains a subject of ongoing debate.
Methods: This prospective nonrandomized controlled trial included
149 consecutive patients with acute anterior circulation stroke who
underwent EVT. The primary outcome was functional independence
assessed by the modified Rankin Scale (mRS) after 3 months.
Results: A total of 105 (70.5%) and 44 (29.5%) patients undergoing
EVT who received conscious sedation (CS) and general anesthesia
(GA), respectively. The patients who received GA had similar dem-
ographics and basic National Institute of Health Stroke Scale scores
(17 vs. 16, P>0.05) as the patients who received CS. The recanali-
zation time (304 vs. 311 min, P=0.940) and the recanalization rate
(86.4% vs. 84.1%, P=0.170) did not differ between the patients
receiving the different types of anesthesia. The National Institute of
Health Stroke Scale at 24 hours was lower in the patients who received
CS than in those who received GA (β=−2.26, 95% confidence
interval, −5.30 to 0.79). The independence (modified Rankin Scale
score 0 to 2) at 3 months was equal between patients who received GA
and those who received CS (odds ratio =0.73, 95% confidence interval,
0.32-1.68). The mortality and the morbidity rates did not differ.
Conclusions: The data indicated that the selection of GA or CS
during EVT had no impact on the independent outcomes of
patients with anterior circulation occlusion.
Key Words: acute ischemic stroke, anesthesia, large artery
occlusion, outcome
(J Neurosurg Anesthesiol 2018;00:000–000)
Acute stroke is one of the leading causes of death and
long-term disability,1particularly in China. Timely
reperfusion of the occluded large vessel through endo-
vascular treatment (EVT) is effective for decreasing neu-
ronal damage and improve outcomes.2,3 However, there is
no definite evidence on the selection of anesthesia for acute
ischemic stroke (AIS) patients undergoing EVT.
General anesthesia (GA) and local anesthesia, with or
without conscious sedation (CS), are commonly used dur-
ing EVT.4,5 However, the association between anesthesia
selection and independent outcomes is controversial. Ob-
servational studies have indicated that acute stroke patients
receiving GA for EVT had worse outcomes than those who
underwent local anesthesia, with or without CS,6–12 and
this finding was confounded by several factors.13 The con-
clusion has been debated in completed randomized con-
trolled trials (RCTs) in which anesthesia choice was
randomized.14–16 In addition, there is still no evidence from
China on the association between anesthesia selection and
clinical outcomes, in which large artery atherosclerosis was
the primary etiological diagnosis.
The aim of the study was to prospectively investigate
the anesthesia strategy and the associated independent
outcomes, which were derived from the intervention arm
of the Endovascular Therapy for Acute Ischemic Stroke
Trial (EAST). The specific hypothesis was that local an-
esthesia, with or without CS, improved 90-day in-
dependence in AIS patients compared with GA.
METHODS
Design
The EAST trial was a multicentre, prospective, non-
randomized controlled study conducted in 17 stroke centers
across China, and consecutive patients with AIS were recruited
Received for publication November 28, 2017; accepted March 12, 2018.
From the Departments of *Anesthesiology; †Interventional Neurology;
and ‡Neurology, Tiantan Clinical Trial and Research Center for
Stroke, Beijing Tiantan Hospital, Capital Medical University, Beijing,
PR China.
Z.M. and R.H. contributed equally.
Y.P., Z.M., and R.H.: helped with the study design and manuscript
preparation. Y.W., J.L., and F.L.: helped with the data collection and
manuscript preparation. X.H. helped with the patient recruitment.
X.L. and Y.Z.: helped with the data collection. P.W. and Y.P.: helped
with the data analyses.
Clinical Trial Registration: www.clinicaltrials.gov (NCT02350283).
The trial was funded by the ‘Youth Program’(QML20150508) and
Hospitals Clinical Medicine Development of Special Funding Sup-
port (ZYLX201708) from the Beijing Municipal Administration of
Hospitals and programs from National Science and Technology
Major Project of China (2011BAI08B02, 2015BAI12B04, and
2015BAI12B02).
The authors have no conflicts of interest to disclose.
Address correspondence to: Ruquan Han, MD, PhD, Department of
Anesthesiology, Beijing Tiantan Hospital, Capital Medical University,
No. 6, Tiantan Xili, Dongcheng District, Beijing 100050, PR China
(e-mail: ruquan.han@gmail.com).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/ANA.0000000000000500
CLINICAL INVESTIGATION
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from January 2015 to August 2015. A central medical ethics
committee (Medical Ethics Committee, Beijing Tiantan
Hospital, Capital Medical University) approved the study
protocol. The EAST trial was registered on Clinicaltrials.gov
(number: NCT02350283). All written informed consent before
study enrolment was provided by legal representatives. The
protocol of the EAST trial has been previously published.17
Patients in the intervention group were treated with mech-
anical recanalization using Solitaire plus standard medical
therapy. Patients in the control group received standard
medical therapy alone.
Patients
Eligible patients were diagnosed with AIS due to large
vessel occlusion indicated for EVT within 12 hours after
symptom onset and met the inclusion criteria: (1) age 18 years
and older; (2) a clinical diagnosis of ischemic stroke, with
symptoms present for at least 30 minutes and without
significant improvement before treatment; (3) a prestroke
modified Rankin Scale (mRS) score ≤1; (4) National In-
stitute of Health Stroke Scale (NIHSS) score ≥8and<30; (5)
occlusion at ≥1 of the following sites (as determined through
single-phase, multiphase or dynamic computed tomography
(CT) angiography or digital subtraction angiography):
carotid T/L, M1-middle cerebral artery (MCA), or M2-MCA
equivalent affecting at least 50% of the MCA territory;
and (6) provided written informed consent. Patients with an
Alberta Stroke Program Early CT Score (ASPECTS) from 0
to 6 in the area of symptomatic intracranial occlusion or a
DWI lesion volume >50 mL were excluded from the study.
Patients in the control arm receiving standard medical ther-
apy alone were excluded from the study.
Exposure
All patients in the intervention arm underwent com-
plete 4-vessel cerebral angiography performed by fully trained
interventional neuroradiologists. When the diagnostic an-
giography revealed arterial occlusion, thrombectomy with a
Solitaire stent was performed as the primary treatment. At
the end of treatment, recanalization was classified according
to the modified thrombolysis in cerebral infarction (mTICI)
perfusion grade.18
GA was defined as induction and maintenance with
sedation drugs, analgesic agents and muscle relaxants,
with controlled ventilation under tracheal intubation or
laryngeal mask, from the time of groin puncture to the end
of the procedure. If a patient underwent tracheal in-
tubation before entering the procedural room, the patient
was excluded from the analysis. CS was defined as local
anesthesia and spontaneous breathing, with or without
administration of sedatives throughout the procedure.
Conversion from CS to GA during the procedure was
another exclusion criterion. The selection of anesthesia
was not predefined in the protocol.
Outcomes
The primary outcome was functional independence
as defined by a mRS of 0 to 2 and assessed by a neurol-
ogist who was blinded to the treatment details at 90 days
after the EVT during an outpatient visit. If a patient was
unable to come to the clinic, the mRS score was assessed
through a telephone interview. The mRS was a 7-point
scale ranging from 0 (no symptoms) to 6 (deceased).
The secondary outcomes were arterial reperfusion of the
occluded target vessel measured by mTICI (2b-3) at the end of
treatment by 2 experienced neurointerventionalists who were
blinded to the clinical data and outcomes. The periprocedural
hemodynamic parameters were recorded including systolic
blood pressure (SBP), diastolic blood pressure, and mean ar-
terial pressure (MAP). The neurological assessment was
measured by using the NIHSS score (range from 0 to 42, with
higher scores indicating more severe neurological deficits) at
2 hours, 24 hours, and 7 days after the procedure. Quality of
life was evaluated by the European life quality (EQ-5D) score
and the Barthel Index (BI) score at 90 days. The rates of
device-related and procedure-related complications were
evaluated and recorded at discharge. Death due to any cause
at 90 days was measured. Symptomatic intracerebral
hemorrhage was detected by CT or magnetic resonance
imaging at 24 ± 3 hours postprocedure. An economic (cost-
effectiveness) analysis, including the total length of intensive
care unit and hospital stays and the inpatient cost in US
dollars, was performed at discharge.
Statistical Analysis
The EAST trial was an exploratory study that aimed
to observe the safety and the efficacy of Solitaire throm-
bectomy in patients with AIS. The sample size of the AIS
patients undergoing EVT was prospectively calculated as
150. Descriptive statistics were reported as the means with
SDs for normally distributed data, medians with inter-
quartile ranges for skewed continuous data, and counts
(percentages) for categorical data. Categorical variables
were analyzed with the χ
2
test, and continuous variables
were analyzed using the Student ttest or Wilcoxon test
between patients who received GA and CS.
Binary and continual outcomes were analyzed
through logistic and linear regression, and the results were
reported as adjusted and unadjusted odds ratios (ORs)
and βcoefficients, with 95% confidence intervals (CIs),
respectively. The primary outcome was adjusted for po-
tential imbalances in known prognostic variables, as re-
ported by previous literature and our differential
comparison results, including age, sex, body mass index,
smoke history, NIHSS on admission, treatment with
r-tPA, onset-to-recanalization time and mTICI (2b-3).
Statistical significance was declared with a type I error of
0.05. SPSS 17.0 (SPSS Inc., Chicago, IL) was used for the
statistical analyses.
RESULTS
Patient Characteristics
Among the 149 patients enrolled in the trial, 44 (29.5%)
underwent GA, and 105 (70.5%) received CS (Fig. 1).
The demographics, past medical history, baseline
NIHSS, results of laboratory studies, and occlusion site
did not differ between the patients receiving different types
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of anesthesia (P>0.05, see Table 1) with the exception of
sex and puncture-to-recanalization time. The male sex
proportion (54.3% vs. 79.6%, P=0.004), and puncture-to-
recanalization time (50, 35 to 85 vs. 73, 46 to 109;
P=0.028) differed, but the onset-to-recanalization time
and recanalization rate, evaluated as mTICI 2b-3, did not
differ between the patients who received CS and those who
received GA.
No patients were lost to follow-up. The primary
outcome, independence (mRS score 0 to 2) at 3 months,
did not differ between the patients who received CS and
those who received GA either before (OR, 0.72; 95% CI,
0.35-1.48) or after the adjustments (OR, 0.73; 95% CI,
0.32-1.68, Table 2). Moreover, we did not observe a shift
in the distribution of the mRS score in favor of the CS
group compared with the GA group (Fig. 2).
After EVT, the NIHSS at 24 hours for patients re-
ceiving CS was significantly lower than that for the patients
who received GA (8.3-15 vs. 11.9-15.5, P=0.038); however,
the NIHSS at 2 hours and 7 days did not differ (Table 2). The
other outcomes, such as the BI score (75 to 100), EQ-5D, and
mortality and morbidity rates (symptomatic intracerebral
hemorrhage and complications with instruments and
operations), did not differ between the patients undergoing
CS and GA. The length of intensive care unit and hospital
stay, and the total inpatient cost in US dollars were similar
between the patients receiving GA and CS.
Among the patients who received local anesthesia at 14
centers, 7 (6.7%) patients did not receive any sedative, and 98
(93.3%) patients received sedatives. In contrast, only 23 pa-
tients who received CS at 2 centers were administered sedatives
by the anesthesiologists, and the other 75 were administered by
the interventionists. Dexmedetomidine was the most frequently
used sedative (48, 45.7%). Among the patients who received
GA at 12 centers, all were administered anesthesia by anes-
thesiologists. Sufentanil (37, 84.1%), with etomidate (22, 50%)
or propofol (19, 43.2%), was often used to induce GA, and
propofol, with (15, 34.1%) or without (28, 63.6%) volatile
agents, was used for maintenance (Table 3).
SBP and MAP were found to be significantly lower
in patients who received GA 30 minutes after induction
compared with patients who received CS at the respective
time points (Fig. 3). However, the number of patients who
received vasoactive drugs was not significantly different
between the 2 anesthesia types (Table 4). The fluid input
for patients receiving GA included crystalloid (618 ± 248
mL) and colloid solution (685 ± 300 mL), whereas only
crystalloid (650 ± 124 mL) was administered to patients
who received CS, and the difference in the input amount
was significant (P<0.05).
FIGURE 1. Flow diagram of the patients included in the study.
TABLE 1. Basic Characteristics and Interventional Parameters
Conscious
Sedation
(N =105)
General
Anesthesia
(N =44) P
Age (median [IQR]) (y) 65.0 (56-73) 61.5 (52-69) 0.131
Sex, male (n [%]) 57 (54.3) 35 (79.6) 0.004*
Body mass index
(median [IQR])
23.6 (22.0-25.5) 24.0 (22.5-26.0) 0.188
mRS 0-2 (n [%]) 99 (94.29) 42 (95.45) 1.000
TOAST type (n [%]) 0.239
Large artery
atherosclerosis
43 (41.0) 26 (59.1)
Cardioembolism 50 (47.6) 15 (34.1)
Stroke of other
determined etiology
3 (2.8) 1 (2.3)
Stroke of
undetermined
etiology
9 (8.6) 2 (4.5)
Atrial fibrillation (n [%]) 45 (42.9) 15 (34.1) 0.320
Hypertension (n [%]) 62 (59.1) 22 (50.0) 0.310
Diabetes mellitus (n [%]) 8 (7.6) 6 (13.6) 0.251
Hypercholesterolemia
(n [%])
4 (3.8) 3 (6.8) 0.422
Ischemic heart disease
(n [%])
2 (1.9) 3 (6.8) 0.153
History of ischemic
stroke (n [%])
12 (11.4) 4 (9.1) 0.896
Smoking history (n [%]) 27 (25.7) 16 (36.4) 0.191
NIHSS on admission
(median [IQR])
16 (12-19) 17 (12-21.5) 0.585
Site of occlusion (n [%]) 0.630
Internal carotid artery 27 (25.7) 13 (29.6)
Middle cerebral artery 78 (74.3) 31 (70.4)
Laboratory test (mean [SD]) (mmol/L)
Blood glucose 7.4 (2.8) 6.8 (1.8) 0.216
Blood creatinine 75.1 (29.5) 74.3 (21.3) 0.567
Blood urea nitrogen 6.1 (2.1) 6.9 (6.3) 0.626
ASPECTS on CT
(median [IQR])
9 (8-10) 9 (8-10) 0.238
Treatment with r-tPA
(n [%])
21 (20.0) 4 (9.1) 0.104
Workflow time in minutes (median [IQR])
Door-to-puncture 115 (60-165) 104 (71-147) 0.896
Puncture-to-
recanalization
50 (35-85) 73 (46-109) 0.028*
Onset-to-
recanalization
304 (243-440) 311 (240-470) 0.940
mTICI score 0.170
2b-3 (n [%]) 89 (86.4) 37 (84.1)
Missing data (n) 2 0
ASPECT indicates Alberta Stroke Program Early CT Score; CT, computed
tomography; DBP, diastolic blood pressure; IQR, interquartile range; mRs,
modified Rankin Scale; mTICI, modified thrombolysis in cerebral infarction;
NIHSS, National Institute of Health Stroke Scale; r-tPA, recombinant tissue-type
plasminogen activator; SBP, systolic blood pressure; TOAST, Trial of Org 10172 in
Acute Stroke Treatment.
*Indicates significance at a P-value of <0.05.
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DISCUSSION
This anesthesia-related analysis of a multicentre,
prospective study assessed the association between anes-
thesia selection and outcomes from the EVT for AIS. The
primary outcome of independence (mRS 0-2) at 3 months,
as well as the mortality and morbidity rates, did not differ
between the patients who received GA and those who
received CS; however, the hemodynamic parameters and
the fluid input were significantly different between the
patients receiving the 2 types of anesthesia.
Previous observational studies have found better
90-day independent outcomes in patients who received CS6;
however, the imbalance in age,19 ischemic severity,7,8,10,11,20
and ischemic site21 led to concern with regard to the
TABLE 2. Primary and Secondary Outcomes
Conscious
Sedation
(N =105)
General
Anesthesia
(N =44) P
Effect
Parameter
Unadjusted Effect of
Conscious Sedation vs. GA
(95% CI)
Adjusted Effect of Conscious
Sedation vs. GA (95% CI)
mRS 0-2 (n [%])
At 7 d or discharge 42 (40.4) 16 (36.4) 0.647 OR 1.19 (0.57-2.46) 1.33 (0.58-3.04)
At 90 d 56 (53.3) 27 (61.4) 0.368 OR 0.72 (0.35-1.48) 0.73 (0.32-1.68)
NIHSS (median [IQR])
At 2 h 11 (7-16) 13.5 (10-19) 0.067 β−2.19 (−4.68 to 0.31) −1.95 (−4.18 to 0.28)
At 24 h 8 (3-15) 11 (9-15.5) 0.038* β−2.07 (−5.10 to 0.95) −2.26 (−5.30 to 0.79)
At 7 d 6 (2-13) 8 (2-11) 0.407 β−0.62 (−3.51 to 2.27) −1.24 (−4.03 to 1.55)
BI score of 75-100 (n [%])
At 7 d or discharge 46 (46.0) 18 (41.7) 0.648 OR 1.18 (0.58-2.44) 1.47 (0.65-3.30)
At 90 d 63 (60.0) 29 (65.9) 0.498 OR 0.78 (0.37-1.62) 0.88 (0.38-2.04)
EQ-5D at 90 d (median
[IQR])†
6 (5-10) 7 (5-9) 0.802 β0.13 (−0.99 to 1.27) −0.26 (−1.40 to 0.88)
Symptomatic ICH at
24 h (n [%])
5 (4.76) 1 (2.27) 0.671 OR 2.15 (0.24-18.95) 2.25 (0.23-22.06)
Complication with
instrument (n [%])
10 (9.52) 5 (11.36) 0.769 OR 0.82 (0.26-2.56) 0.57 (0.16-2.10)
Complication with
operation (n [%])
11 (10.48) 6 (13.64) 0.580 OR 0.74 (0.26-2.15) 0.71 (0.23-2.24)
Mortality at 90 d
(n [%])
13 (12.4) 5 (11.4) 0.862 OR 1.10 (0.37-3.30) 1.12 (0.33-3.87)
ICU stay (median
[IQR]) (d)‡
4 (1-7) 5 (2-8) 0.582 β−0.19 (−2.71-2.32) −0.19 (−2.90-2.51)
Total hospital stay
(median [IQR]) (d)
14 (8-22) 14 (9-22) 0.781 β1.54 (−5.15-8.23) −0.43 (−7.08-6.23)
Total cost in
thousands of
dollars (mean [SD])
12.7 (7.8) 14.6 (5.3) 0.122 β−12.52 (−30.36-5.32) −12.45 (−30.77-5.86)
Adjusted by age, sex, body mass index, smoke history, NIHSS on admission, treatment with r-tPA, onset-to-recanalization time and mTICI (2b-3). OR calculated as the
odds in the conscious sedation group versus that in the general anesthesia group.
*Indicates significance at a P-value of <0.05.
†The number of missing values was 24.
‡The number of missing values was 13.
BI indicates Barthel Index; EQ-5D, 5-dimension European quality of life; ICU, intensive care unit; IQR, interquartile range; mRs, modified Rankin Scale; NIHSS1,
National Institute of Health Stroke Scale; OR, odds ratio.
FIGURE 2. mRS at 90 days divided by general anesthesia and conscious sedation. The numbers and percentages of patients are
shown in each cell according to the distribution of mRS scores (range 0 to 6, with 0 to 2 indicating no symptoms to slight disability
and 3 to 6 indicating moderate disability to death). The shift in the distribution on the mRS between groups is shown (P=0.5523).
mRS indicates modified Rankin Scale.
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selection bias and a cautious interpretation of the con-
clusion. Moreover, the association was also confounded by
the intraprocedural parameters, such as the decrease in
MAP >40%,22 the minimal diastolic blood pressure and
the maximal SBP variability.21 Therefore, the preprocedure
ischemia (site and severity) and the intraprocedure hemo-
dynamic fluctuation were often regarded as confounding
factors between anesthesia selection and independence
after EVT. The sensitivity analysis from the recent
metaanalysis23 indicated that the pooled incidence of
independence (mRS score 0 to 2) from the RCTs favored
GA; however, patients receiving GA had significantly
higher morbidity and mortality rates compared with patients
who received CS. Therefore, the evidence for selection of
anesthesia for AIS patients undergoing EVT still requires
results from a diverse population. Our results were from a
nonrandomized study. However, the baseline NIHSS, the
ischemic site, and the other preprocedure parameters were
all comparable between the patients receiving the 2 types of
anesthesia, and the primary outcome was also in accordance
with the AnStroke trial,15 which studied the same subjects
with anterior circulation ischemia. However, the other 2
recently completed trials, both SIESTA14 and GOLIATH,16
favored GA from the point of better 90-day independent
outcome (mRS score 0 to 2).
The time from onset-to-recanalization is critical for
the independent outcome in AIS patients after EVT,
which may be affected by the etiological cause of ischemia.
Good clinical outcomes at 90 days (mRS 0-2) was greatest
TABLE 3. Anesthetic Drugs Administered
N (%)
Conscious sedative
Diazepam 7 (6.7)
Midazolam 18 (17.1)
Propofol 22 (20.9)
Dexmedetomidine 48 (45.7)
Phenobarbital 3 (2.8)
General anesthesia induction
Fentanyl 6 (13.6)
Sufentanil 37 (84.1)
Remifentanil 1 (2.3)
Propofol 19 (43.2)
Dexmedetomidine 2 (4.5)
Etomidate 22 (50)
Midazolam 1 (2.3)
General anesthesia maintenance
Continual infusion of propofol 28 (63.6)
Inhalation 1 (2.3)
Combined infusion of propofol with inhalation 15 (34.1)
FIGURE 3. Hemodynamic changes during endovascular treatment. Preprocedural blood pressure was defined as the pressure
obtained immediately on arrival in the angiography suite. & represents anesthesia induction in patients receiving GA, while &
represents arterial puncture in patients receiving local anesthesia, with or without CS. *Compared with patients who received CS,
P<0.05. CS indicates conscious sedation; DBP, diastolic blood pressure; GA, general anesthesia; MAP, mean arterial pressure;
SBP, systolic blood pressure.
TABLE 4. Fluid Input and Vasoactive Drug Used
Conscious
Sedation
(N =105)
General
Anesthesia
(N =44) P
Centers 17 12 NA
Fluid input (mean [SD])
(mL)
650 (124) 968 (414) 0.034
Crystalloid 650 (124) 618 (248) 0.058
Colloid NA 685 (300) NA
Vasodilator (n [%]) 30 (28.6) 11 (25.0) 0.656
Urapidil 18 (17.1) 9 (20.5) 0.632
Nicardipine 12 (11.4) 2 (4.5) 0.315
Vasoconstrictor (n [%]) NA 3 (6.8) NA
Ephedrine NA 1 (2.3) NA
Dopamine NA 1 (2.3) NA
Phenylephrine NA 1 (2.3) NA
NA indicates not applicable.
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with time from symptom onset to arterial puncture of
under 2 hours and became nonsignificant after 7.3 hours,24
and was also closely related with the time to reperfusion.25
The TOAST classification of large artery atherosclerosis
was found in 69 patients (46.3%) in our trial, and the
onset-to-puncture time in our study was ~238 and
254 minutes in patients who received GA and CS, re-
spectively, both of which were in the suggested effective
time window. In addition, the onset-to-recanalization time
in our trial (304 min in CS vs. 311 min in GA) was slightly
longer than that in the AnStroke trial (250 min in CS vs.
254 min in GA),15 comparable with that reported in the
MR CLEAN trial (349 min in CS vs. 334 min in GA)12
and shorter than those in some previous observational
studies.9,26 In the current trial, the recanalization time
would not influence the association between anesthesia
selection and outcomes in AIS patients undergoing EVT.
The proportion of GA administered to patients un-
dergoing EVT was higher in some observational studies10,20
than that in our study; however, in some recent trials,12,19,27
this proportion was lower than those found in the above-
mentioned observational studies. It often takes more time to
prepare GA induction and tracheal intubation than to pre-
pare CS for patients, and needs more cooperation from
anesthesiologists. Therefore, CS was the first choice of the
interventional neurologists for EVT. In the EAST trial,
the mean difference between GA and CS in door-to-puncture
time (11 min) and onset-to-recanalization time (7 min) were
acceptable. This small time difference might be explained by
the fact that a special team of anesthesiologists was on duty at
the intervention-treatment room to conduct all GA, but the
agents for CS were administered by the anesthesiologists in
only 23 cases (23.5%) in 2 centers (13.3%) and by the inter-
ventionists for the other cases. This time difference was not the
confounding factor between anesthesia selection and in-
dependence for the patients who received EVT.
In the EAST trial, dexmedetomidine was the most
frequently used agent (45.7%) during sedation; however,
all administrations were performed by interventionists. In
addition, no patients received analgesic or colloid during
CS. Hence, a series of problems for AIS patients under
sedation could occur, including substantial movement,
respiratory depression and high conversion rate from se-
dation to GA. Even in the SIESTA14 trial, in which the
anesthesia selection was randomized, a high rate of sub-
stantial movement, diverse drug choices and a high rate of
conversion from CS to GA were detected. However, the
number of movement and respiratory parameters were not
recorded in the EAST trial. In addition, the proportions of
induction with sufentanil and etomidate and maintenance
with total intravenous anesthesia increased in this study
compared with the study conducted by Jagani et al,21 in
which fentanyl and propofol were primarily used. SBP and
MAP were significantly decreased within 30 minutes after
induction; however, the number of patients who received
vasoactive drugs, particularly a vasoconstrictor, did not
differ between the patients under the 2 anesthesia types,
and a >40% decrease in MAP from the preprocedure
value was not found in patients receiving GA.
This study has several limitations. First, the data
were from a nonrandomized trial, and the anesthesia
choice was decided by the interventional neurologists.
However, the baseline characteristics of ischemia and
demographics were well balanced. Second, the sample size
was not calculated but predefined in the EAST trial and
might be not sufficient to test the difference in 90-day mRS
between the different anesthesia types. However, we cal-
culated the power for testing the primary outcome divided
by the anesthesia type as >85%. Third, some anesthesia-
specific information was not collected in detail, including
the ventilator parameters, end-expiratory carbon dioxide
and real-time hemodynamic parameters, which might be
potential risk factors for the independent outcome. How-
ever, the EAST study was an exploratory trial and had
provided a foundation for further research in such pop-
ulations, such as the ongoing CANVAS trial,5a multi-
centre, parallel-group RCT observing the effect of
anesthesia selection on independent outcome in patients
with acute anterior circulation stroke undergoing EVT.
CONCLUSIONS
Among patients with AIS in the anterior circulation
undergoing EVT, CS compared with GA did not result in
more improvements in the independent status at 3 months
after the procedure. RCTs are still needed to provide more
perioperative evidence of the hemodynamics and respira-
tion effects of anesthesia choice on outcomes of patients
with AIS during EVT.
ACKNOWLEDGMENTS
We gratefully acknowledge the enrolled centers and
investigators for their outstanding work. The following
centers and investigators were involved: Ya Peng, MD,
Department of Neurosurgery, Changzhou No. 1 People’s
Hospital, Changzhou, China; Yibin Cao, MD, Department
of Neurology, Tangshan Gongren Hospital, Tangshan,
China; Shengli Chen, MD, Department of Neurology,
Chongqing Sanxia Central Hospital, Chongqing, China;
Meng Zhang, MD, Department of Neurology, Daping
Hospital, Chongqing, China; Changchun Jiang, MD, De-
partment of Neurology, Baotou Central Hospital, Baotou,
China; Xiaoxiang Peng, MD, Department of Neurology,
Hubei Zhongshan Hospital, Wuhan, China; Cunfeng Song,
MD, Department of Neurology, Liaocheng 3rd People’s
Hospital, Liaocheng, China; Liping Wei, MD, Department
of Neurology, Luoyang Central Hospital Affiliated to
Zhengzhou University, Luoyang, China; Qiyi Zhu, MD,
Department of Neurology, People’s Hospital of Linyi City,
China; Zaiyu Guo, MD, Department of Neurology, Tianjin
Teda Hospital, Tianjin, China; Li Liu, MD, Department of
Neurology, Chifeng Municipal Hospital, Chifeng, China;
Hang Lin, MD, Department of Neurology, Fuzhou PLA
General Hospital, Fuzhou, China; Hua Yang, MD, De-
partment of Neurology, Affiliated Hospital of Guiyang
Medical College, Guiyang, China; Wei Wu, MD, Department
of Neurology, QiLu Hospital of ShanDong University, Jinan,
China; Hui Liang, MD, Department of Neurology, Yantai
Peng et al J Neurosurg Anesthesiol Volume 00, Number 00, ’’ 2018
6
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www.jnsa.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
This paper can be cited using the date of access and the unique DOI number which can be found in the footnotes.

Hill Hospital, Yantai, China; Anding Xu, MD, Department of
Neurology, The First Affiliated Hospital of Jinan University,
China; and Kangning Chen, MD, Department of Neurology,
Xinan Hospital, China.
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J Neurosurg Anesthesiol Volume 00, Number 00, ’’ 2018 Outcomes After Acute Ischemic Stroke With Anesthesia
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Copyright r2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
This paper can be cited using the date of access and the unique DOI number which can be found in the footnotes.