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Introduction Current evidence supports endovascular therapy (EVT) for eligible patients with acute ischemic stroke in the anterior and posterior circulation. However, there is no consensus regarding the choice of anesthetic approach during EVT and early reported studies were observational with potential biases and confounding. Therefore, we sought to build concrete evidence from randomized clinical trials (RCTs) comparing the general anesthesia (GA) vs. non‐GA via a systematic review and meta‐analysis approach. Methods Data from inception to June 2023 were reviewed and only RCTs comparing the GA vs. non‐GA were included. We then pooled data for the main procedural, safety, and efficacy outcomes with odds ratios (ORs) and 95% CI for dichotomous data and mean difference (MD) with 95% CI for continuous data under random effect model. Results Eight RCTs were included in the final analysis (n=1203) with seven of them reporting data for the anterior circulation (n=1116) and one for the posterior circulation (n=87). Regarding efficacy outcomes, pooled results revealed non‐statistically significant difference between GA and non‐GA for functional independence at 90 days defined as modified Rankin Score scale of 0‐2 (OR = 1.17, 95% CI: 0.88–1.56, P= 0.28; I2 = 26%, Figure A) and the results of the anterior circulation subgroup showed non‐statistically significant difference (OR = 1.22, 95% CI: 0.90–1.67, P= 0.2; I2 = 31%) and the difference was not also evident for posterior circulation (48.8% vs 54.5%; RR, 0.89; 95% CI, 0.58‐1.38; adjusted OR, 0.91; 95% CI, 0.37‐2.22). Successful recanalization, defined as Thrombolysis in Cerebral Infarction score of 2b‐3, showed a statistically significant results favoring GA over non‐GA (OR = 1.94, 95% CI: 1.42–2.63, P=0.0001; I2 = 0%, Figure B) and this continued to show statistically significant in both anterior and posterior circulation subgroups. Onset to reperfusion time was not statistically significant between GA and non‐GA (MD, ‐2.59; 95% CI: ‐22.38 to 17.21, P= 0.8; I2=24%, Figure C). Regarding safety outcomes, there were no statistically significant differences in intracranial hemorrhage (OR = 0.95, 95% CI: 0.67–1.35, p = 0.79; I2 =0%, Figure D) or mortality (OR = 0.95, 95% CI: 0.71–1.29, p = 0.76; I2 =0%, Figure E). However, GA showed a higher risk of hypotension compared to non‐GA (OR = 6.05, 95% CI: 3.25–11.25, P=0.00001; I2 =69%, Figure F). Sensitivity analysis by leave one out removing Ren et al (5) showed homogenous results (OR = 8.43, 95% CI: 5.85–12.16, P=0.00001; I2 =0%) Conclusion In this study‐level meta‐analysis, GA resulted in higher rates of successful reperfusion as compared to non‐GA despite being associated with higher rates of hypotension. Since many of the included studies were small and single center, more studies are warranted to support these findings. |
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