Role of anesthesia for endovascular treatment of ischemic stroke: do we need neurophysiological monitoring?

The use of acute endovascular stroke intervention was called into question after the results of 2 negative stroke endovascular trials (Interventional Management of Stroke 3 [IMS-3] and Systemic Thrombolysis for Acute Ischemic Stroke per the Stroke Center registry [SYNTHESIS]).1,2 However, the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trial3 compared patients with acute stroke with proximal anterior circulation artery occlusions with usual stroke care, including intravenous tissue-type plasminogen activator (tPA). The study demonstrated a favorable shift in outcomes in the interventional group by modified Rankin Scale (mRS) by 90 days (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.21–2.30). Improvement in mRS was noted for all categories except for death. General anesthesia (GA) was used in 38% of the patients in the interventional group of MR CLEAN. In contrast, 9% of the patients in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE)4 trial received GA. The rate of functional independence (mRS, 0–2 by 90 days) was higher in the intervention group (53.0% versus 29.3%; P u003c0.01). Furthermore, lower mortality rate was seen in intervention group (10.4 versus 19.0; P =0.04). A recent meta-analysis by Fargen5,6 included MR CLEAN and the prior endovascular stroke trials and suggested a favorable shift outcome (mRS, 0–2; good outcome by 90 days; OR, 1.67; 95% CI, 1.29–1.16; P =0.0001) for patients with large-vessel occlusions who receive interventional therapy. In a post hoc analysis of MR CLEAN for use of GA, Berkhemer reported at the International Stroke Conference in Nashville, TN, a favorable effect when non-GA was used instead of GA (mRS, 0–2 at 90 days 38% versus 23%; P =0.013).7 Also, GA was associated with delayed initiation of interventional therapy in comparison with …