General Anesthesia versus Sedation, Both with Hemodynamic Control, during Intraarterial Treatment for Stroke: The GASS Randomized Trial.

BACKGROUND: It is speculated that the anesthetic strategy during endovascular therapy for stroke may have an impact on the outcome of the patients. The authors hypothesized that conscious sedation is associated with a better functional outcome 3 months after endovascular therapy for the treatment of stroke compared with general anesthesia. METHODS: In this single-blind, randomized trial, patients received either a standardized general anesthesia or a standardized conscious sedation. Blood pressure control was also standardized in both groups. The primary outcome measure was a modified Rankin score less than or equal to 2 (0 = no symptoms; 5 = severe disability) assessed 3 months after treatment. The main secondary outcomes were complications, mortality, reperfusion results, and National Institutes of Health Stroke Scores at days 1 and 7. RESULTS: Of 351 randomized patients, 345 were included in the analysis. The primary outcome occurred in 129 of 341 (38%) of the patients: 63 (36%) in the conscious sedation group and 66 (40%) in the general anesthesia group (relative risk, 0.91 [95% CI, 0.69 to 1.19]; P = 0.474). Patients in the general anesthesia group experienced more intraoperative hypo- or hypertensive episodes, while the cumulative duration was not different (mean ± SD, 36 ± 31 vs. 39 ± 25 min; P = 0.079). The time from onset and from arrival to puncture were longer in the general anesthesia group (mean difference, 19 min [i.e., -00:19] [95% CI, -0:38 to 0] and mean difference, 9 min [95% CI, -0:18 to -0:01], respectively), while the time from onset to recanalization was similar in both groups. Recanalization was more often successful in the general anesthesia group (144 of 169 [85%] vs. 131 of 174 [75%]; P = 0.021). The incidence of symptomatic intracranial hemorrhage was similar in both groups. CONCLUSIONS: The functional outcomes 3 months after endovascular treatment for stroke were similar with general anesthesia and sedation. Our results, therefore, suggest that clinicians can use either approach.

Intravenous abciximab as a rescue therapy for immediate reocclusion after successful mechanical thrombectomy in acute ischemic stroke patients.

Immediate reocclusion after mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is a rare but devastating condition associated with poor functional outcome. The aim of this study was to gain insights into the mechanisms underlying immediate reocclusion, and to evaluate the efficacy and safety of the glycoprotein IIb/IIIa antagonist abciximab, for its treatment. Clinical data were collected from April 2015 to April 2019 in a monocentric prospective registry of AIS patients treated by MT. All patients with immediate reocclusion were retrospectively selected and subdivided into 2 groups according to abciximab treatment status. In vitro, the separate and combined effects of abciximab and alteplase on clot formation in whole blood under flow conditions were further investigated in microfluidic chambers. From 929 MT-treated patients, 21 had post-MT immediate reocclusion. Abciximab treatment in reocclusion patients (n = 10) led to higher rate of final recanalization (p < .001) while it did not increase bleeding complications. Flow chamber experiments revealed that, in contrast to alteplase, abciximab efficiently limits thrombus accretion from flowing blood by blocking platelet aggregation. Our results underscore a key role for platelet aggregation and the potential of Glycoprotein IIb/IIIa antagonists as a rescue therapy in post-MT immediate reocclusion.

Effect of Steady and Dynamic Blood Pressure Parameters During Thrombectomy According to the Collateral Status.

Background and Purpose- Guidelines regarding blood pressure (BP) management during endovascular therapy (EVT) for anterior circulation strokes are questionable since the optimal BP target is a matter of debate. To evaluate the importance of hemodynamic control during EVT, we investigated the impact of dynamic and steady BP parameters during EVT on functional outcome (part 1) and according to the collateral status (CS; part 2). Methods- We performed a post hoc analysis of the ASTER trial (Contact Aspiration Versus Stent Retriever for Successful Recanalization). BP was measured noninvasively during EVT and CS assessed on the angiographic run before EVT. We studied dynamic BP parameter using BP variability (coefficient of variation) and steady BP parameter (hypotension time defined as systolic BP <140 mm Hg and mean arterial pressure <90 mm Hg). The primary outcome was favorable outcome defined as a 3-month modified Rankin Scale score between 0 and 2. Results- Among the 381 patients of the ASTER study, 172 patients were included in part 1 and 159 in part 2. Systolic BP, diastolic BP, and mean arterial pressure variability were negatively associated with favorable outcome regardless of CS: per 10-unit increase, adjusted odds ratios were 0.45 (95% CI, 0.20-0.98), 0.37 (95% CI, 0.19-0.72), and 0.35 (95% CI, 0.16-0.76), respectively. According to CS, the hypotension time with periprocedural mean arterial pressure <90 mm Hg was negatively associated with favorable outcome in patients with poor CS (adjusted odds ratio, 0.88 [95% CI, 0.72-1.09]) but not in patients with good CS (adjusted odds ratio, 1.24 [95% CI, 0.91-1.67]; Phet=0.047). Conclusions- The CS did not modify the association between dynamic parameters and functional outcomes, but some findings suggest that the CS modifies the association between steady parameter and functional outcomes. Hypotension time according to the CS was not statistically predictive of poor outcomes but displayed a trend toward worse outcomes for patients with poor CS only.

Association of Blood Pressure During Thrombectomy for Acute Ischemic Stroke With Functional Outcome: A Systematic Review.

Background and Purpose- Optimal blood pressure (BP) targets during mechanical thrombectomy (MT) for acute ischemic stroke (AIS) are unknown, and randomized controlled trials addressing this issue are lacking. We aimed to perform a systematic review of studies evaluating the influence of periprocedural BP on functional outcome after MT. Methods- Studies assessing periprocedural BP effect on functional outcome published after January 1st, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work. Results- Nine studies were included, for a total of 1037 patients. The heterogeneity in findings with respect to BP monitoring and studied parameters precluded a meta-analysis. Mean arterial pressure was the most frequently reported parameter to describe BP variability during MT, and systolic BP was the main parameter used to define periprocedural BP targets. Five studies suggested an association between 3 types of BP drops as predictors of poor functional outcome at 3 months: >40% drop in mean arterial pressure compared with baseline (odds ratio=2.8; [1.09-7.19]; P=0.032), lowest mean arterial pressure before recanalization (odds ratio=1.28; [1.01-1.62] per 10 mm Hg drop below 100 mm Hg; P=0.04), and MAP drops (odds ratio=4.38; [1.53-12.6] for drops >10%). Four studies did not show an association between BP during MT and functional outcome, including 3 studies with strict periprocedural systolic BP targets (within a 140-180 mm Hg). Conclusions- BP drops during MT may be associated with a worse functional outcome. When strict systolic BP targets are achieved, no association between BP and functional outcome was also noted. Both conclusions require further evaluation in randomized studies.

Predictors of Parenchymal Hematoma After Mechanical Thrombectomy: A Multicenter Study

Background and Purpose: Parenchymal hematoma (PH) is a rare but dreadful complication of acute ischemic stroke with unclear underlying mechanisms. We aimed to study the incidence and predictors of PH after mechanical thrombectomy. Methods: Data from a prospective observational multicenter registry was screened to identify acute ischemic stroke patients with an anterior circulation large vessel occlusion who underwent mechanical thrombectomy. Clinical, imaging, and procedural characteristics were used for the analysis, including brain imaging systematically performed at 24 hours. PH occurrence was assessed according to ECASS (European Collaborative Acute Stroke Study) criteria. Univariate and multivariable analyses were performed to identify predictors of PH. Results: A total of 1316 patients were included in the study. PH occurred in 153 out of 1316 patients (11.6%) and was associated with a lower rate of favorable outcome and increased mortality. On multivariable analysis, age (per 1 year increase, odds ratio [OR], 1.01; 95% CI, 1.00­1.03; P=0.05), current smoking (OR, 2.02; 95% CI, 1.32­3.09; P<0.01), admission Alberta Stroke Program Early CT Score (per a decrease of 1 point, OR, 1.70; 95% CI, 1.18­2.44; P<0.01), general anesthesia (OR, 1.98; 95% CI, 1.36­2.90; P<0.001), angiographic poor collaterals (OR, 2.13; 95% CI, 1.36­3.33; P<0.001) and embolization in new territory (OR, 2.94; 95% CI, 1.70­5.10; P<0.001) were identified as independent predictors of PH. Conclusions: PH occurred at a rate of 11.6% after mechanical thrombectomy, with high morbidity and mortality. Our study identified clinical, radiological, and procedural predictors of PH occurrence that can serve as the focus of future periprocedural management studies with the aim of reducing its occurrence.

Predictors of the Aspiration Component Success of a Direct Aspiration First Pass Technique (ADAPT) for the Endovascular Treatment of Stroke Reperfusion Strategy in Anterior Circulation Acute Stroke.

BACKGROUND AND PURPOSE: A direct aspiration first pass technique (ADAPT) has been reported to be fast, safe, and effective for the treatment of acute ischemic stroke. The aim of this study is to determine the preoperative factors that affect success of the aspiration component of the technique in ischemic stroke patients with large vessel occlusion in the anterior circulation. METHODS: We enrolled all 347 consecutive patients with anterior circulation acute ischemic stroke admitted for mechanical thrombectomy at our institution from August 2013 to October 2015 and treated by ADAPT for the endovascular treatment of stroke. Baseline and procedural characteristics, modified thrombolysis in cerebral infarction scores, and 3-month modified Rankin Scale were captured and analyzed. RESULTS: Among the 347 patients (occlusion sites: middle cerebral artery=200, 58%; internal carotid artery Siphon=89, 25%; Tandem=58, 17%), aspiration component led to successful reperfusion (modified thrombolysis in cerebral infarction 2b/3 scores) in 55.6% (193/347 patients), stent retrievers were required in 40%, and a total successful final reperfusion rate of 83% (288/347) was achieved. Overall, procedural complications occurred in 13.3% of patients (48/347). Modified Rankin Scale score of 0 to 2 at 90 days was reported in 45% (144/323). Only 2 factors positively influenced the success of the aspiration component: an isolated middle cerebral artery occlusion (P<0.001) and a shorter time from stroke onset to clot contact (P=0.018). CONCLUSIONS: In this large retrospective study, ADAPT was shown to be safe and effective for anterior circulation acute ischemic stroke with a final successful reperfusion achieved in 83%. The site of arterial occlusion and delay of the procedure were predictors for reperfusion. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02523261, NCT02678169, and NCT02466893.

Preliminary Experience with Cangrelor for Endovascular Treatment of Challenging Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Cangrelor is a P2Y12 inhibitor that presents the advantage of having a short half-life. Its use may be helpful in the management of antiplatelet therapy for patients with intracranial aneurysms treated by stent-assisted coiling or flow-diverter stents. The purpose of this study was to report early experiences in using cangrelor for such indications. MATERIAL AND METHODS: From October 2017 to November 2018, 7 consecutive patients (5 females, 2 males, mean age = 56 years) were managed with cangrelor as antiplatelet therapy, combined with aspirin, for stent-assisted coiling embolization and flow-diverter embolization of challenging intracranial aneurysms. Anti-aggregation protocols, including cangrelor, were systematically recorded. Treatment-related complications (minor/major hemorrhagic complications, ischemic complications) as well as clinical and angiographic outcomes (evaluated at 8.7 ± 4.2 and 8.75 ± 10 months, respectively) were retrospectively analyzed. RESULTS: Of the aneurysms 71.4% (5 out of 7) were ruptured and treated in the acute phase. In one case cangrelor was used as an alternative to clopidogrel in an asymptomatic hemorrhagic complication after stent-assisted coiling for better control of a possible worsening of the intracranial bleeding. Of the patients, 1 (14%) with a complex ruptured MCA aneurysm treated with a flow-diverter stent experienced a severe intracranial hemorrhage, which occurred after switching the cangrelor to ticagrelor and eventually led to death. No hemorrhagic complications under cangrelor were recorded for the six remaining patients. No mRS worsening was observed at discharge, except for the patient who died and six out of the seven patients had a mRS ≤2 at follow-up. CONCLUSION: Cangrelor is a new antiplatelet therapy with a P2Y12 inhibiting effect, with a rapid onset and offset of action, owing to its short half-life. This cases series presents a pilot experience with promising results in terms of antiplatelet management for challenging intracranial aneurysms treated by stent assisted coiling or flow-diverter stents.

Neutrophil count predicts poor outcome despite recanalization after endovascular therapy.

OBJECTIVE: To identify early prognostic factors of poor clinical outcome in patients treated by endovascular therapy (EVT) with successful recanalization. METHODS: We reviewed our monocentric prospectively collected EVT database of patients with anterior circulation acute ischemic stroke (AIS) from January 2016 to April 2018 who had achieved successful recanalization (Thrombolysis in Cerebral Infarction score ≥ 2b) at the end of the procedure. A poor outcome was defined as a 3-month modified Rankin Scale score of ≥3. RESULTS: A total of 324 patients were included, among whom 186 (57.4%) had a poor outcome. Multivariate logistic regression indicated that age (per 10-year increase, odds ratio [OR] 1.34, 95% confidence interval [CI] 1.12-1.60), baseline NIH Stroke Scale score (per 1-unit increase, OR 1.09, 95% CI 1.04-1.15), initial infarct volume (per a log+1 increase, OR 1.34, 95% CI 1.05-1.67), blood glucose level (per a log+1 increase, OR 2.60, 95% CI 1.01-6.66), and neutrophil count (per 1,000-unit increase, OR 1.08, 95% CI 1.01-1.17) were all associated with poor clinical outcome. CONCLUSIONS: In addition to baseline severe AIS criteria, high neutrophil count and high blood glucose, known from experimental studies to be associated with downstream microvascular thromboinflammation, are independently associated with poor outcome. These findings support a deleterious role of thromboinflammation in patient recovery despite successful recanalization.

Successful Use of Recombinant Activated Factor VII to Reverse Ticagrelor-Induced Bleeding Risk: A Case Report.

Management of ticagrelor-associated bleeding is challenging, especially in neurosurgery. Platelet transfusion is inefficient and no antidote is currently available. We report here the first case of recombinant activated factor VII (rFVIIa) use to bypass ticagrelor-induced platelet inhibition. A woman treated with ticagrelor and requiring emergent neurosurgery for an intracranial hematoma received preoperative high-dose platelet transfusion and 60 µg/kg rFVIIa. Laboratory monitoring demonstrated that platelet transfusion failed to reverse ticagrelor-induced platelet inhibition while rFVIIa improved hemostasis by shortening the thromboelastometric clotting time. Neurosurgery occurred without any bleeding event but the patient presented with a postoperative pulmonary embolism. In conclusion, rFVIIa may decrease ticagrelor-induced bleeding risk but careful assessment of the benefit-risk balance is warranted before using rFVIIa to reverse ticagrelor effects.

Prognostic Significance of Pulse Pressure Variability During Mechanical Thrombectomy in Acute Ischemic Stroke Patients.

Background Studies on the role of blood pressure ( BP ) variability specifically during mechanical thrombectomy ( MT ) are sparse and limited. Moreover, pulse pressure ( PP ) has not been considered as a potent hemodynamic parameter to describe BP variability during MT . We assessed the impact of PP variability on functional outcome in acute ischemic stroke patients with large vessel occlusion during MT . Methods and Results Acute ischemic stroke patients presenting with large vessel occlusion from January 2012 to June 2016 were included. BP data during MT were prospectively collected in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Logistic regression models were used to assess the association between PP coefficients of variation and functional outcome at 3 months (modified Rankin Scale). Among the 343 included patients, PP variability was significantly associated with worse 3-month modified Rankin Scale in univariable (odds ratio [OR] =1.56, 95% confidence interval [CI]: 1.24-1.96 per 1-unit increase, P=0.0002) and multivariable ordinal logistic regression (adjusted OR =1.40, 95% CI : 1.09-1.79, P=0.008). PP variability was also associated with unfavorable outcome (modified Rankin Scale 3-6) in univariable ( OR =1.53, 95% CI : 1.17-2.01, P=0.002) and multivariable analysis (adjusted OR =1.42, 95% CI : 1.02-1.98, P=0.04). There was an association between PP variability and 3-month all-cause mortality in univariable analysis ( OR = 1.37, 95% CI : 1.01-1.85 per 1-unit increase of the coefficient of variation of the PP , P=0.04), which did not remain significant after adjustment for potential confounders. Conclusions PP variability during MT is an independent predictor of worse clinical outcome in acute ischemic stroke patients. These findings support the need for a close monitoring of BP variability during MT . Whether pharmacological interventions aiming at reducing BP variability during MT could impact functional outcome needs to be determined.

The comparability of bispectral index and state entropy index during maintenance of sufentanil-sevoflurane-nitrous oxide anesthesia.

BACKGROUND: Manufacturers recommend maintaining Bispectral (BIS) or Spectral Entropy (State Entropy, SE) indexes between 40 and 60 during the maintenance of anesthesia. We compared these indexes during this period. METHODS: Data were obtained from 58 patients receiving sufentanil-sevoflurane-nitrous oxide anesthesia. The anesthesiologist was blinded to BIS and SE. Artifact-free concurrent BIS and SE values (7792 pairs), automatically recorded at 1-min intervals, were compared using Bland-Altman analysis, Kappa coefficient for agreement and crude proportion of agreement. The occurrence of errors of judgment (Type 1 defined as one parameter <40 and the other >60, or Type 2 defined as BIS and SE values on different sides of a threshold [40 or 60]) was also counted. RESULTS: Bias was -2 with limits of agreement of -18 and 9. Kappa BIS/SE obtained from all patients was 0.537 +/- 0.147; crude agreement >0.80 was observed in 45% of patients. Type 1 number of errors of judgment corresponded to two instances. Median and interquartile values of Type 2 number of errors of judgment were 4.5 [3.0-6.0] when considering a difference between BIS and SE more than 5. CONCLUSION: Although limits of agreement between BIS and SE were large, Kappa value moderate, and crude agreement <0.80 in more than half of the patients, making completely contradictory decisions (e.g., deepening the anesthetic based on one parameter and lightening it based upon the other) would have been exceptional. More common would have been a risk of error between no change versus increasing or decreasing anesthetic depth.

Mortality and Disability According to Baseline Blood Pressure in Acute Ischemic Stroke Patients Treated by Thrombectomy: A Collaborative Pooled Analysis.

BACKGROUND: High blood pressure (BP) is associated with worse clinical outcomes in the setting of acute ischemic stroke, but the optimal blood pressure target is still a matter of debate. We aimed to study the association between baseline BP and mortality in acute ischemic stroke patients treated by mechanical thrombectomy. METHODS AND RESULTS: A total of 1332 acute ischemic stroke patients treated by mechanical thrombectomy were enrolled (from January 2012 to June 2016) in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Linear and polynomial logistic regression models were used to assess the association between BP and mortality and functional outcome at 90 days. Highest mortality was found at lower and higher baseline systolic blood pressure (SBP) values following a J- or U-shaped relationship, with a nadir at 157 mm Hg (95% confidence interval 143-170). When SBP values were categorized in 10-mm Hg increments, the odds ratio for all-cause mortality was 3.78 (95% confidence interval 1.50-9.55) for SBP<110 mm Hg and 1.81 (95% confidence interval 1.01-3.36) for SBP≥180 mm Hg using SBP≥150 to 160 mm Hg as reference. The rate of favorable outcome was the highest at low SBP values and lowest at high SBP values, with a nonlinear relationship; in unplanned exploratory analysis, an optimal threshold SBP≥177 mm Hg was found to predict unfavorable outcome (adjusted odds ratio 0.47; 95% confidence interval 0.31-0.70). CONCLUSION: In acute ischemic stroke patients treated by mechanical thrombectomy, baseline SBP is associated with all-cause mortality and favorable outcome. In contrast to mortality, favorable outcome rate was the highest at low SBP values and lowest at high SBP values. Further studies are warranted to confirm these findings.

Does monitoring bispectral index or spectral entropy reduce sevoflurane use?

A decrease in volatile anesthetic consumption has been demonstrated using bispectral index (BIS), whereas data concerning spectral entropy are lacking. One hundred and forty adult patients scheduled for surgical procedures lasting more than 1 h were prospectively randomized to receive an anesthetic controlled either by BIS or by spectral entropy or solely by clinical variables. Anesthesia was induced with propofol and sufentanil. Sufentanil was infused continuously thereafter. Sevoflurane was administered in 1 L/min O2/N2O. The sevoflurane concentration was adjusted according to conventional clinical variables in the standard practice group, whereas the 40-60 interval was applied for the BIS and spectral entropy-guided groups. The sevoflurane vaporizer was weighed before and after anesthesia, and consumption was calculated. Groups were comparable for demographic data except for weight (heavier in the spectral entropy-guided group, P < 0.05). Compared with standard practice, patients with BIS or spectral entropy monitoring required 29% less sevoflurane (normalized sevoflurane consumption to the weights of the patients and to the durations of anesthesia; both P < 0.03) and a similar sufentanil dose. An unintended improvement in the standard practice group (positive bias) was observed. In conclusion, BIS and spectral entropy monitoring have the same sparing effect of sevoflurane.

Is platelet transfusion efficient to restore platelet reactivity in patients who are responders to aspirin and/or clopidogrel before emergency surgery?

PURPOSE: The aim of this study was to confirm that emergency platelet transfusion effectively restores platelet function to patients receiving antiplatelet therapy (APT) with aspirin and/or clopidogrel. PATIENTS AND METHODS: This was a prospective observational case report series conducted between January 1, 2009, and January 1, 2012. All responder patients according to the Verify Now device requiring emergency platelet transfusion because of a potentially life-threatening hemorrhage or before emergency neurosurgery were included. Aspirin or P2Y12-specific tests were used as appropriate for patients under aspirin or clopidogrel. Patients who were responders to aspirin had an aspirin reaction unit of less than 550, and patients who were responders to clopidogrel had an inhibition percentage of more than 20%. The Verify Now test was performed again after platelet transfusion. Pretransfusion and posttransfusion test results were compared. RESULTS: During the 36-month period, 25 patients met the inclusion criteria. Of these patients, 4 were receiving dual APT, 8 were receiving clopidogrel only, and 13 were receiving aspirin only. The average platelet transfusion dose was 0.12 UI/kg (range, 0.10-0.14 UI/kg). For patients under clopidogrel, the inhibition percentage lowered significantly after transfusion (median 54 [range, 31-69] before and 25 [range, 18-50] after transfusion; p < 0.005) but remained above the 20% threshold. Our patients were still responsive to clopidogrel after platelet transfusion. This result is conflicting with the existing literature. The median aspirin reaction unit of aspirin users before and after transfusion were 420 (range, 400-470) and 630 (range, 610-640), respectively (p = 0.001). The efficacy of platelet transfusion to restore aspirin-mediated disaggregation is confirmed by our case series. CONCLUSION: Platelet transfusion does not restore platelet function in patients under clopidogrel, but it is efficient for patients under aspirin. This sheds new light on previous large-scale studies that have been unable to show any effectiveness of emergency platelet transfusion in patients under APT. Emergency platelet transfusion may only be indicated in aspirin users who are responders and not in all patients under APT as is actually recommended.

Paravertebral block with ropivacaine 0.5% versus systemic analgesia for pain relief after thoracotomy.

PURPOSE: Paravertebral block in combination to intravenous analgesics could be an alternative to epidural analgesia for postoperative pain control after thoracotomy, but it has been scarcely evaluated so far. We thus assessed the efficacy of paravertebral block using a continuous infusion of ropivacaine in a multimodal analgesic approach. DESCRIPTION: Forty patients were randomized to receive ketoprofen, paracetamol, and patient-controlled-analgesia (PCA) with intravenous morphine (control group) or the same treatment with a continuous 48-hour infusion of ropivacaine 0.5% (0.1 mL/kg(-1)/h(-1)) in a thoracic paravertebral catheter (thoracic paravertebral block [TPVB] group). Visual analog scale (VAS) at rest and when coughing, morphine consumption, and side effects were recorded during the first 48 hours after surgery. Venous blood was sampled at 24 and 48 hours for ropivacaine plasma concentration measurements. EVALUATION: Mean VAS scores at rest and when coughing were significantly decreased in the TPBV group (p < 0.005). Despite a decrease in the morphine-titrated dose given in the postanesthesia care unit, cumulated morphine consumption was not significantly different between the two groups (51 +/- 29 mg and 57 +/- 24 mg in the TPVB and control groups, respectively). Side effects (nausea, vomiting, urinary retention) were less frequent in the TPBV group (30% vs 75%; p < 0.005). Plasma ropivacaine concentrations remained below the toxic threshold. CONCLUSIONS: Continuous paravertebral ropivacaine 0.5% infusion improves pain control after thoracic surgery using a multimodal analgesic approach.