Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of Interventional Management of Stroke (IMS) III Trial.
Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of Interventional Management of Stroke (IMS) III Trial.
复制标题
DOI：
10.1161/strokeaha.115.008761
复制
发表时间：
2015-08
期刊：
影响因子：
8.3
通讯作者：
Hill MD
中科院分区：
文献类型：
--
作者：
Abou-Chebl A;Yeatts SD;Yan B;Cockroft K;Goyal M;Jovin T;Khatri P;Meyers P;Spilker J;Sugg R;Wartenberg KE;Tomsick T;Broderick J;Hill MD
急性缺血性中风(AIS)血管内治疗(EVT)的全身麻醉(GA)可能与较差的预后相关。IMS III试验将AIS发病3小时内的患者随机分为IVt-PA±EVT组。根据方案记录卒中发作后7小时内GA的使用情况。好的结果定义为90天的MRS≤2。对二分的NIHSS(8-19比≥20)、年龄和从发病到腹股沟穿刺术的时间进行了多因素分析。434例患者被随机分为两组，局麻组2 69例(62%)，全麻组14 7例(33 9%)，未确定组18例(4%)。除中位数基线NIHSS外，两组均可比(局麻组16例，局麻组18例，p<；0.0001)。GA组获得良好结果的可能性较小(调整后RR0.68，CI0.52-0.90；p=0.0056)，住院死亡率增加(调整后RR2.84，CI1.65-4.91；p=0.0002)。那些有医学提示的GA患者的预后更差(调整后的RR0.49，CI0.30-0.81，p=0.005)，死亡率更高(RR3.93，CI2.18-7.10；P<；0.0001)，而常规GA的死亡率更高。调整后的SAH风险(p=0.32)和症状性脑出血风险(p=0.37)没有显著差异。GA与较差的神经预后和EVT组的死亡率增加有关；这主要是在具有GA医学适应症的患者中是正确的。相对风险估计，虽然不具有统计学意义，但表明在局部麻醉下SAH和SICH的风险降低。尽管这些关联的原因尚不清楚，但这些数据支持在EVT期间尽可能使用局部麻醉。
General anesthesia (GA) for endovascular therapy (EVT) of acute ischemic stroke (AIS) may be associated with worse outcomes. The IMS III trial randomized patients within 3hrs of AIS onset to IV t-PA±EVT. GA use within 7hrs of stroke onset was recorded per protocol. Good outcome was defined as 90day mRS≤2. A multivariable analysis adjusting for dichotomized NIHSS (8-19 versus ≥20), age, and time from onset to groin puncture was performed. Four hundred thirty-four patients were randomized to EVT, 269(62%) were treated under local anesthesia and 147(33.9%) under GA; 18(4%) were undetermined. The two groups were comparable except for median baseline NIHSS (16 local anesthesia versus 18 [GA], p<0.0001). The GA group was less likely to achieve a good outcome (adjusted-RR 0.68, CI 0.52-0.90; p=0.0056) and had increased in-hospital mortality (adjusted-RR 2.84, CI 1.65-4.91; p=0.0002). Those with medically indicated GA had worse outcomes (adjusted RR 0.49, CI 0.30-0.81, p=0.005) and increased mortality (RR 3.93, CI 2.18-7.10; p<0.0001) with a trend for higher mortality with routine GA. There was no significant difference in the adjusted risks of SAH (p=0.32) or symptomatic ICH (p=0.37). GA was associated with worse neurological outcomes and increased mortality in the EVT arm; this was primarily true among patients with medical indications for GA. Relative risk estimates, though not statistically significant, suggest reduced risk for SAH and sICH under local anesthesia. Although the reasons for these associations are not clear, these data support the use of local anesthesia when possible during EVT.