Letter by Rasmussen et al Regarding Article, “Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis”
2017; Lippincott Williams & Wilkins; Volume: 49; Issue: 1 Linguagem: Inglês
10.1161/strokeaha.117.019573
ISSN1524-4628
AutoresMads Rasmussen, Claus Z. Simonsen, Deepak Sharma,
Tópico(s)Traumatic Brain Injury and Neurovascular Disturbances
ResumoHomeStrokeVol. 49, No. 1Letter by Rasmussen et al Regarding Article, “Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Rasmussen et al Regarding Article, “Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis” Mads Rasmussen, MD, PhD and Claus Z. Simonsen, MD, PhD Deepak Sharma, MBBS, MD, DM Mads RasmussenMads Rasmussen Departments of Anesthesia and Intensive Care, Section of Neuroanesthesia and Neurology, Aarhus University Hospital, Denmark Search for more papers by this author and Claus Z. SimonsenClaus Z. Simonsen Departments of Anesthesia and Intensive Care, Section of Neuroanesthesia and Neurology, Aarhus University Hospital, Denmark Search for more papers by this author Deepak SharmaDeepak Sharma Department of Anesthesiology and Pain Medicine, University of Washington, Seattle Search for more papers by this author Originally published8 Dec 2017https://doi.org/10.1161/STROKEAHA.117.019573Stroke. 2018;49:e20Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2017: Previous Version 1 To the Editor:We read with great interest the recent systematic review and meta-analysis by Brinjiki et al1 on anesthesia-related outcomes in endovascular treatment (EVT) for acute ischemic stroke. This is the second systematic review and meta-analysis within recent years from this group on the same topic, now including a few additional studies and not surprisingly with much the same conclusion.2As stated by the authors, there is currently an ongoing debate regarding the optimal anesthetic strategy for EVT in acute ischemic stroke. In recent years, a considerable amount of retrospective studies have suggested that general anesthesia (GA) during EVT is associated with worse outcome. These studies are nicely summarized in the meta-analysis by Brinjiki et al.1 However, we are concerned about the selection and combination of studies for this meta-analysis and doubt its conclusion.Although the authors performed a bias assessment, it does not remove the fact that the included retrospective studies are biased, simply because of the retrospective design and because of selection of sicker patients in the GA group. Anesthetic preferences of neurointerventionalists, neurologists, and anesthesiologists in addition to frequent lack of hemodynamic and anesthetic data also add to bias these studies. In the current meta-analysis by Brinjiki et al,1 the authors also included the 2 recently published single-center randomized studies (SIESTA [Sedation vs Intubation for Endovascular Stroke Treatment] and AnStroke [Anesthesia During Stroke])3,4 in addition to unpublished data from the GOLIATH investigators (General or Local Anesthesia in Intra Arterial Therapy),5 which were presented at a scientific meeting. In contrast to the vast majority of the retrospective studies, these randomized controlled trials did not find superiority of conscious sedation over GA and in fact, rather suggested advantages of GA. The addition of data from these randomized studies seems to justify the need to provide another systematic review and meta-analysis on this subject. However, regardless of the data from the randomized studies, the inclusion of multiple biased retrospective studies undoubtedly still produces a biased meta-analysis. The aim of a meta-analysis is through rigorous assessment of the included studies to derive a pooled estimate of the common effect. In our opinion, it is only relevant to include prospective randomized data in a meta-analysis to enhance the understanding of the association between anesthesia method and neurological outcome after EVT. The older retrospective studies provide no clear definition of GA and do not include anesthesiologists to verify that the patients classified as receiving conscious sedation actually did not receive GA without airway instrumentation. There is a high likelihood that significant heterogeneity in pharmacological choices, physiological implications, and assessment of the level of sedation impacted proper classification and results in the retrospective studies. Thus, combining the prospective studies with the retrospective studies specifically in this study population seems hugely problematic.Overall, there is still a very limited amount of prospective data within this field, and we would like to encourage researchers to provide high-quality prospective randomized data to further elucidate the optimal method of anesthesia for EVT in acute ischemic stroke. Meanwhile, the results of the meta-analysis by Brinjiki et al must be interpreted with caution.On behalf of the SAGA (SIESTA-AnStroke-GOLIATH-Association) investigators (Silvia Schönenberger, Julian Bösel, Pia Löwhagen Henden, Alexandros Rentzos, Niels Juul).3–5Mads Rasmussen, MD, PhDClaus Z. Simonsen, MD, PhDDepartments of Anesthesia and Intensive CareSection of Neuroanesthesia and NeurologyAarhus University HospitalDenmarkDeepak Sharma, MBBS, MD, DMDepartment of Anesthesiology and Pain MedicineUniversity of WashingtonSeattleDisclosuresNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 4 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.References1. Brinjikji W, Pasternak J, Murad MH, Cloft HJ, Welch TL, Kallmes DF, et al. Anesthesia-related outcomes for endovascular stroke revascularization: a systematic review and meta-analysis.Stroke. 2017; 48:2784–2791. doi: 10.1161/STROKEAHA.117.017786.LinkGoogle Scholar2. Brinjikji W, Murad MH, Rabinstein AA, Cloft HJ, Lanzino G, Kallmes DF. Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis.AJNR Am J Neuroradiol. 2015; 36:525–529. doi: 10.3174/ajnr.A4159.CrossrefMedlineGoogle Scholar3. Schönenberger S, Uhlmann L, Hacke W, Schieber S, Mundiyanapurath S, Purrucker JC, et al. Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy: a randomized clinical trial.JAMA. 2016; 316:1986–1996. doi: 10.1001/jama.2016.16623.CrossrefMedlineGoogle Scholar4. Löwhagen Hendén P, Rentzos A, Karlsson JE, Rosengren L, Leiram B, Sundeman H, et al. general anesthesia versus conscious sedation for endovascular treatment of acute ischemic stroke: the AnStroke trial (Anesthesia During Stroke).Stroke. 2017; 48:1601–1607. doi: 10.1161/STROKEAHA.117.016554.LinkGoogle Scholar5. Simonsen CZ, Sørensen LH, Juul N, Johnsen SP, Yoo AJ, Andersen G, et al. Anesthetic strategy during endovascular therapy: general anesthesia or conscious sedation? (GOLIATH - General or Local Anesthesia in Intra Arterial Therapy) a single-center randomized trial.Int J Stroke. 2016; 11:1045–1052. doi: 10.1177/1747493016660103.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Sharma D, Rasmussen M, Han R, Whalin M, Davis M, Kofke W, Venkatraghvan L, Raychev R and Fraser J (2020) Anesthetic Management of Endovascular Treatment of Acute Ischemic Stroke During COVID-19 Pandemic: Consensus Statement From Society for Neuroscience in Anesthesiology & Critical Care (SNACC), Journal of Neurosurgical Anesthesiology, 10.1097/ANA.0000000000000688, 32:3, (193-201), Online publication date: 1-Jul-2020. Goyal N, Malhotra K, Ishfaq M, Tsivgoulis G, Nickele C, Hoit D, Arthur A, Alexandrov A and Elijovich L (2018) Current evidence for anesthesia management during endovascular stroke therapy: updated systematic review and meta-analysis, Journal of NeuroInterventional Surgery, 10.1136/neurintsurg-2018-013916, 11:2, (107-113), Online publication date: 1-Feb-2019. January 2018Vol 49, Issue 1 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.117.019573PMID: 29222225 Originally publishedDecember 8, 2017 PDF download Advertisement SubjectsIschemic Stroke
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