Anesthesia and neurologic outcome of endovascular therapy in acute ischemic stroke

Recent trials have confirmed the effectiveness of endovascular mechanical thrombectomy for selected acute ischemic stroke patients with large artery occlusion, whose outcomes remained poor despite optimal medical management. Among many challenges for thrombectomy implementation is determining whether general anesthesia (GA) reduces the benefits of thrombectomy, as several recent studies suggest.1,2Berkhemer et al.3approach this question with a post hoc analysis of Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), the first prospective, randomized study to compare endovascular treatment (predominantly mechanical thrombectomy using stent retrievers) with best medical care (including IV thrombolysis) to medical care alone for CT angiography–proven large artery stroke.4The analysis reveals a 51% decrease in the primary treatment effect—outcome on the modified Rankin Scale (mRS) at 90 days—in those treated under GA, and negative effects on secondary outcomes, including recanalization rate, infarct volume, and stroke progression.3In fact, endovascular therapy was only beneficial when GA was not used. These results agree with several prior studies1,2and, if correct, carry implications for clinical care.