The effect of anesthetic management during intra-arterial therapy for acute stroke in MR CLEAN.

Berkhemer, Olvert A; van den Berg, Lucie A; Fransen, Puck S S; Beumer, Debbie; Yoo, Albert J; Lingsma, Hester F; Schonewille, Wouter J; van den Berg, René; Wermer, Marieke J H; Boiten, Jelis; Lycklama À Nijeholt, Geert J; Nederkoorn, Paul J; Hollmann, Markus W; van Zwam, Wim H; van der Lugt, Aad; van Oostenbrugge, Robert J; Majoie, Charles B L M; Dippel, Diederik W J; Roos, Yvo B W E M and Mattle, Heinrich (2016). The effect of anesthetic management during intra-arterial therapy for acute stroke in MR CLEAN. Neurology, 87(7), pp. 656-664. Lippincott Williams & Wilkins 10.1212/WNL.0000000000002976

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BACKGROUND

The aim of the current study was to assess the influence of anesthetic management on the effect of treatment in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN).

METHODS

MR CLEAN was a multicenter, randomized, open-label trial of intra-arterial therapy (IAT) vs no IAT. The intended anesthetic management at the start of the procedure was used for this post hoc analysis. The primary effect parameter was the adjusted common odds ratio (acOR) for a shift in direction of a better outcome on the modified Rankin Scale (mRS) at 90 days, estimated with multivariable ordinal logistic regression analysis, which included a term for general anesthesia (GA).

RESULTS

GA was associated with significant (p = 0.011) effect modification, resulting in estimated decrease of 51% (95% confidence interval [CI] 31%-86%) in treatment effect compared to non-GA. We found a shift in the distribution on the mRS in favor of non-GA compared to control group (acOR 2.18 [95% CI 1.49-3.20]). The shift in distribution between GA and control group was in a similar direction (acOR 1.12 [95% CI 0.71-1.78]) with loss of statistical significance.

CONCLUSIONS

In this post hoc analysis, we found that the type of anesthetic management influences outcome following IAT. Only treatment without general anesthesia was associated with a significant treatment benefit in MR CLEAN.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that for patients with acute ischemic stroke undergoing IAT, mRS scores at 90 days improve only in patients treated without GA.

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