General Anesthesia Versus Conscious Sedation for Mechanical Thrombectomy in Patients With Acute Ischemic Stroke in the MOST Trial

BACKGROUND: Several observational studies have supported the use of conscious sedation (CS) for endovascular thrombectomy in patients with acute ischemic stroke and associated general anesthesia (GA) with poor functional outcomes. Recently, few randomized controlled trials have shown no difference in the functional outcomes between GA and CS. The aim of this paper is to compare the outcomes of GA versus CS in patients with acute ischemic stroke undergoing mechanical thrombectomy in the MOST (Multi-arm Optimization of Stroke Thrombolysis) trial. METHODS: Patients who underwent mechanical thrombectomy for acute ischemic stroke under GA or CS in the MOST trial were included. The primary outcome of interest was the utility weighted modified Rankin Scale (mRS) score at 90days after stroke. The secondary outcomes were mRS score ≤1, ≤2 at 90days, 90-day mRS score, thrombolysis in cerebral infarction 2B or better, 24-hour National Institutes of Health Stroke Scale score, 24-hour change in National Institutes of Health Stroke Scale score, and 90-day mortality. RESULTS: A total of 219 patients underwent mechanical thrombectomy with 101 patients receiving GA and 118 patients receiving CS. Our analysis showed that GA was associated with a lower average utility weighted mRS score at 90days compared with CS (P≤0.02). Similarly, GA was associated with higher odds of worse outcomes on 90-day mRS 0 to 2 (P<0.001), 90-day mRS median score (P<0.001), a higher 24-hour National Institutes of Health Stroke Scale score (P<0.001), and a lower change in baseline 24-hour National Institutes of Health Stroke Scale score (P<0.001). A sensitivity analysis of patients with anterior stroke alone also favored better neurologic outcomes in the CS group compared with the GA group. CONCLUSIONS: In patients undergoing endovascular thrombectomy in the MOST trial, GA was associated with poorer functional outcomes compared with CS.