知识更新：全身麻醉对脑卒中血管介入治疗的安全性和预后的影响

pingchi1983

Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of Interventional Management of Stroke (IMS) III Trial.全身麻醉对于脑卒中血管介入治疗安全性和远期预后的影响评估

AbstractBACKGROUND AND PURPOSE:

General anesthesia (GA) for endovascular therapy (EVT) of acute ischemic stroke may be associated with worse outcomes.

METHODS:

The Interventional Management of Stroke III trial randomized patients within 3 hours of acute ischemic stroke onset to intravenous tissue-type plasminogen activator±EVT. GA use within 7 hours of stroke onset was recorded per protocol. Good outcome was defined as 90-day modified Rankin Scale ≤2. A multivariable analysis adjusting for dichotomized National Institutes of Health Stroke Scale (NIHSS; 8-19 versus ≥20), age, and time from onset to groin puncture was performed.

RESULTS:

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 2 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 relative risk, 0.68; confidence interval, 0.52-0.90; P=0.0056) and had increased in-hospital mortality (adjusted relative risk, 2.84; confidence interval, 1.65-4.91; P=0.0002). Those with medically indicated GA had worse outcomes (adjusted relative risk, 0.49; confidence interval, 0.30-0.81; P=0.005) and increased mortality (relative risk, 3.93; confidence interval, 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 subarachnoid hemorrhage (P=0.32) or symptomatic intracerebral hemorrhage (P=0.37).

CONCLUSIONS:

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 subarachnoid hemorrhage and symptomatic intracerebral hemorrhage under local anesthesia. Although the reasons for these associations are not clear, these data support the use of local anesthesia when possible during EVT.

摘要
背景和目标：全身麻醉下给予急性缺血性脑卒中的病人血管内介入治疗可能临床结局更糟


方法：卒中介入三期临床试验将卒中三小时内的病人随机分成接受组织纤溶酶原激活物伴或不伴血管内介入治疗2组，卒中7小时内均予全身麻醉。90天后改良RANKIN 评分 ≤2视为良好的临床预后，依据病人NIHSS评分，年龄，以及从发病到股动脉置入时间三个参数进行多元素分析。


结果：434名患者进行血管内介入治疗。269名局部麻醉，147名全身麻醉。两组的NIHSS的平均基线有显著性差异（局麻16&全麻18），全麻组临床预后较差（调整RR 0.68，CI 0.52-0.90; P=0.0056），住院期间死亡率增加（调整RR2.84，CI 1.65-4.91; P=0.0002）；有全麻指证的患者比起普通常规的全麻病人临床结局更差，死亡率更高；蛛网膜下腔出血和颅内出血疾病本身无显著性差异。


结论：在血管内介入的病人，全麻与更差的神经功能结局和增加的死亡率相关，尤其是那些有医学全麻指征的病人。虽然不是统计意义的显著差别，RR（相对风险参数）评价局麻下行蛛网膜出血和系统颅内出血病人的血管介入治疗风险降低，提示此类介入治疗尽可能采用局麻。