Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: There is currently controversy on the ideal anesthesia strategy during mechanical thrombectomy for acute ischemic stroke. We performed a systematic review and meta-analysis of studies comparing clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group). METHODS: A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome at 90 days (modified Rankin Score≤2), symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, and time to groin puncture. RESULTS: Twenty-two studies (3 randomized controlled trials and 19 observational studies), including 4716 patients (1819 GA and 2897 non-GA) were included. In the nonadjusted analysis, patients in the GA group had higher odds of death (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66-2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22-2.37) and lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48-0.64) compared with the non-GA group. There was no difference in procedure time between the 2 primary comparison groups. When adjusting for baseline National Institutes of Health Stroke Scale, GA was still associated with lower odds of good functional outcome (OR, 0.59; 95% CI, 0.29-0.94). When considering studies performed in the stent-retriever/aspiration era, there was no significant difference in good neurological outcome rates (OR, 0.84; 95% CI, 0.67-1.06). CONCLUSIONS: Acute ischemic stroke patients undergoing intra-arterial therapy may have worse outcomes when treated with GA as compared with conscious sedation/local anesthesia. However, major limitations of current evidence (ie, retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to answer this question.

Evaluation of the charges, safety, and mortality of percutaneous renal thermal ablation using the nationwide inpatient sample.

PURPOSE: To perform a national analysis of safety, charges, complications, and mortality of percutaneous image-guided renal thermal ablation and compare outcomes by hospital volume. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample, trends in the proportion of inpatient percutaneous renal thermal ablation procedures performed at high-volume centers in the United States from 2007-2011 were evaluated. In-hospital mortality, discharge to long-term care facility, length of stay, hospitalization charges, and postoperative complications were compared between high-volume and low-volume ablation centers. High volume was set at the 90th percentile for renal thermal ablation volume, which equated to seven or more patients per year. A multivariate logistic regression analysis adjusting for hospital volume, age, sex, Charlson Comorbidity Index, obesity, race, and insurance status was performed to analyze the influence of hospital volume on the above-listed outcomes. RESULTS: This study included 874 patients. The number of hospitals ranged from 59-77 depending on year. Overall, 328 patients (37.5%) were treated at high-volume ablation centers. The proportion of patients treated at high-volume centers decreased from 42.0% in 2007-2009 to 28.5% in 2010-2011. High-volume hospitals also performed significantly more partial nephrectomies than low-volume hospitals. On multivariate logistic regression analysis, increasing hospital volume was associated with lower odds of in-hospital mortality (odds ratio [OR] = 0.31, 95% confidence interval [CI] = 0.02-0.95) and lower odds of discharge to a long-term care facility (OR = 0.00, 95% CI = 0.00-0.66). Increasing hospital volume was also associated with lower odds of blood transfusion (OR = 0.84, 95% CI = 0.72-0.94). Length of stay decreased with increasing hospital volume (P = .03). CONCLUSIONS: Patient safety may be maximized when renal ablation is performed at high-volume centers as a result of both greater procedural experience and potentially multidisciplinary triage and periprocedural management.

Minimally conscious state after ruptured giant basilar aneurysm.

OBJECTIVE: To report the clinical and radiologic findings in a case of transient minimally conscious state after rupture and coiling of a giant basilar aneurysm. DESIGN: Case report. SETTING: Neuroscience intensive care unit. PATIENT: A 44-year-old man who developed a transient minimally conscious state in association with perianeurysmal edema in the rostral brainstem and thalamus after rupture and coiling of a giant basilar artery aneurysm. MAIN OUTCOME MEASURE: Correlation of clinical and magnetic resonance imaging findings. RESULTS: A minimally conscious state and bilaterally symmetric vasogenic edema of the rostral brainstem and thalamus developed 2 days after endovascular aneurysm coiling. The clinical and radiologic abnormalities improved significantly and in parallel during the following 4 weeks. CONCLUSIONS: Perianeurysmal vasogenic edema in the brainstem and thalamus can develop after rupture and coiling of a giant basilar artery aneurysm. This process can be transient and can produce dramatic alterations in consciousness that later resolve.