Local anesthesia is associated with better functional outcomes than conscious sedation in endovascular thrombectomy for acute ischemic stroke: A retrospective analysis of the OPTIMISE registry

IntroductionThere are several possible anesthetic strategies during endovascular therapy (EVT) for acute ischemic stroke (AIS), including general anesthesia (GA), conscious sedation (CS), and local anesthesia (LA). While randomized trials have not shown a clear advantage of GA or CS, LA remains understudied. We aimed to determine if LA is associated with better functional outcomes compared to CS in a Canadian EVT registry.Patients and MethodsA retrospective analysis of the OPTIMISE registry was conducted, focusing on adult patients with anterior circulation AIS treated with EVT between January 2018 and December 2021. Patients with available information regarding anesthetic modality and 3-month functional outcome were included. The primary endpoint was a favorable functional outcome at 3 months (defined as a modified Rankin Scale score of 0-2) when using LA compared to CS (average treatment effect [ATE] determined by targeted maximum likelihood estimation). Secondary outcomes included procedural time, favorable reperfusion, complications, and symptomatic intracranial hemorrhage.ResultsA total of 2204 patients were included in the analysis (763 LA, 1441 CS). In the LA group, 57.5% (n = 439) had a favorable outcome at 3 months compared to 55.6% (n = 801) in the CS group (ATE 0.04 [0.00-0.07]; adjusted odds ratio 1.16 [1.01-1.34]; p = 0.04). No significant difference was found between groups regarding reperfusion rates, procedural times, and symptomatic intracranial hemorrhage.ConclusionIn this large, Canadian multicenter cohort of patients undergoing EVT for anterior circulation AIS, LA was safe and led to better functional outcomes at 3 months compared to CS. Given its simplicity and potential benefits, LA warrants greater consideration in clinical practice and inclusion as a treatment arm in future randomized controlled trials studying the optimal anesthetic strategy for EVT.