General anesthesia or conscious sedation for thrombectomy in stroke patients: an updated systematic review and meta-analysis.

PURPOSE: Endovascular treatment for stroke patients usually requires anesthesia care, with no current consensus on the best anesthetic management strategy. Several randomized controlled trials and meta-analyses have attempted to address this. In 2022, additional evidence from three new trials was published: the GASS trial, the CANVAS II trial, and preliminary results from the AMETIS trial, prompting the execution of this updated systematic review and meta-analysis. The primary objective of this study was to evaluate the effects of general anesthesia and conscious sedation on functional outcomes measured with the modified Rankin scale (mRS) at three months. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials investigating conscious sedation and general anesthesia in endovascular treatment. The following databases were examined: PubMed, Scopus, Embase, and the Cochrane Database of Randomized Controlled Trials and Systematic Reviews. The Risk of Bias 2 tool was used to assess bias. In addition, trial sequence analysis was performed on the primary outcome to estimate if the cumulative effect is significant enough to be unaffected by further studies. RESULTS: Nine randomized controlled trials were identified, including 1,342 patients undergoing endovascular treatment for stroke. No significant differences were detected between general anesthesia and conscious sedation with regards to mRS, functional independence (mRS, 0-2), procedure duration, onset to reperfusion, mortality, hospital length of stay, and intensive care unit length of stay. Patients treated under general anesthesia may have more frequent successful reperfusion, though the time from groin to reperfusion was slightly longer. Trial sequential analysis showed that additional trials are unlikely to show marked differences in mean mRS at three months. CONCLUSIONS: In this updated systematic review and meta-analysis, the choice of anesthetic strategy for endovascular treatment of stroke patients did not significantly impact functional outcome as measured with the mRS at three months. Patients managed with general anesthesia may have more frequent successful reperfusion. TRIAL REGISTRATION: PROSPERO (CRD42022319368); registered 19 April 2022.

RéSUMé: OBJECTIF: Le traitement endovasculaire pour les patient·es victimes d'un accident vasculaire cérébral (AVC) nécessite généralement des soins d'anesthésie, mais il n'existe actuellement aucun consensus sur la meilleure stratégie de prise en charge anesthésique. Plusieurs études randomisées contrôlées et méta-analyses ont tenté d'aborder cette question. En 2022, des données probantes supplémentaires provenant de trois nouvelles études ont été publiées : l'étude GASS, l'étude CANVAS II et les résultats préliminaires de l'étude AMETIS, ce qui a motivé la réalisation de cette revue systématique et méta-analyse mises à jour. L'objectif principal de cette étude était d'évaluer les effets de l'anesthésie générale et de la sédation consciente sur les devenirs fonctionnels mesurés avec l'échelle de Rankin modifiée (mRS) à trois mois. MéTHODE: Nous avons réalisé une revue systématique avec méta-analyse d'études randomisées contrôlées portant sur la sédation consciente et l'anesthésie générale dans le traitement endovasculaire. Les bases de données suivantes ont été examinées : PubMed, Scopus, Embase et la base de données Cochrane des études randomisées contrôlées et des revues systématiques. L'outil Risque de biais 2 a été utilisé pour évaluer le biais. De plus, une analyse séquentielle des études a été effectuée sur le critère d'évaluation principal afin d'estimer si l'effet cumulatif était suffisamment significatif pour ne pas être affecté par d'autres études. RéSULTATS: Neuf études randomisées contrôlées ont été identifiées, incluant 1342 patient·es bénéficiant d'un traitement endovasculaire pour un AVC. Aucune différence significative n'a été détectée entre l'anesthésie générale et la sédation consciente en ce qui concerne la mRS, l'indépendance fonctionnelle (mRS, 0-2), la durée de l'intervention, le moment d'apparition de la reperfusion, la mortalité, la durée de séjour à l'hôpital et la durée de séjour en unité de soins intensifs. Les patient·es traité·es sous anesthésie générale pourraient avoir une reperfusion réussie plus fréquente, bien que le temps entre l'aine et la reperfusion était légèrement plus long. L'analyse séquentielle des études a montré qu'il est peu probable que d'autres études montrent des différences marquées dans la mRS moyenne à trois mois. CONCLUSION: Dans cette revue systématique et méta-analyse mises à jour, le choix de la stratégie anesthésique pour le traitement endovasculaire des personnes victimes d'un AVC n'a pas eu d'impact significatif sur les devenirs fonctionnels mesurés avec la mRS à trois mois. La réussite de la reperfusion pourrait être plus fréquente chez les patient·es pris·es en charge par anesthésie générale. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42022319368); enregistrée le 19 avril 2022.

A Comparison Between Enteral and Intravenous Nimodipine in Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis.

Our objective was to compare the effectiveness of intravenous and enteral nimodipine in preventing poor outcome from delayed cerebral ischemia in patients with subarachnoid hemorrhage. We performed a systematic search and a network meta-analysis using the following databases: PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Google Scholar. Risk of Bias 2 tool was used to assess risk of bias of included studies. A ranking among methods was performed on the basis of the frequentist analog of the surface under the cumulative ranking curve. Published studies that met the following population, intervention, comparison, outcomes and study (PICOS) criteria were included: patients with subarachnoid hemorrhage aged 15 years or older (P); nimodipine, intravenous and oral formulation (I); placebo or no intervention (C); poor outcome measured at 3 months (defined as death, vegetative state, or severe disability), case fatality at 3 months, delayed cerebral ischemia, delayed ischaemic neurologic deficit, and vasospasm measured with transcranial Doppler or digital subtraction angiography (O); and randomized controlled trials (S). No language or publication date restrictions were applied. Ten studies were finally included, with a total of 1527 randomly assigned patients. Oral and intravenous nimodipine were both effective in preventing poor outcome, delayed cerebral ischemia, and delayed ischaemic neurological deficit. Neither treatment was effective in improving case fatality. Evolving clinical protocols over a 30-year period and the risk of bias of the included studies may limit the strength of our results. Enteral and intravenous nimodipine may have a similar effectiveness in terms of preventing poor outcome, delayed cerebral ischemia, and delayed ischaemic neurological deficit. More research may be needed to fully establish the role of intravenous nimodipine in current clinical practice.

Early exposure to general anesthesia impairs social and emotional development in rats.

Several animal and emerging human studies suggest an association between an early exposure to general anesthesia (GA) and long-lasting problems with complex social and emotional behaviors such as inattentiveness, impulsivity, anxiogenic tendencies, as well as difficulties engaging in proper social intercourse, with significant increase in attention deficit and hyperactivity-type behaviors. To further investigate these behaviors, and to examine the potential of presently available rodent behavioral models to guide future assessments of long-term socio-emotional impairments in humans, we examined the long-term effects of GA on anxiety/fear and social behaviors. We exposed male and female Sprague-Dawley infant rats at the peak of their synaptogenesis to either GA containing midazolam (9 mg/kg, i.p.), 70% nitrous oxide (N2O) and 0.75% isoflurane (Iso) administered in 29-30% oxygen (experimental), or air (with 30% oxygen) plus the vehicle, 0.1% dimethyl sulfoxide (Sham) for 6 h. Behavioral experiments were conducted at adolescence (the open-field test) and young adulthood (the open-field test, the elevated plus-maze and the social novelty test). We report that an early exposure to GA during critical stages of brain development results in long-lasting increase in risk-taking tendencies and significant changes in the anxiety-related behaviors when tested in young adult rats. In addition, we noted novelty-seeking tendencies/less guarded behavior with changes in social discrimination. We conclude that early exposure to anesthesia may have lasting influences on emotional and social development. Importantly, our results show that currently used rodent behavioral models could be a good correlate to assess long-term socio-emotional GA-induced impairments observed in humans.

Lung ultrasound as a monitoring tool in lung transplantation in rodents: a feasibility study.

BACKGROUND: Orthotopic lung transplantation in rats has been developed as a model to study organ dysfunction, but available tools for monitoring the graft function are limited. In this study, lung ultrasound (LUS) is proposed as a new non-invasive monitoring tool in awake rodents. METHODS: LUS was applied to native and graft lung of six rats after left orthotopic transplantation. Rats were monitored with LUS while awake, patterns identified, images evaluated with a scoring system, intra- and inter-rater agreement was assessed and examination times analyzed. RESULTS: A total of 78 clips were recorded. The median quality score of LUS was 3.66/4 for left hemithorax and 3.71/4 for native right side. The intra-rater agreement was 0.53 and 0.65 and the inter-rater agreement was 0.61 (P<0.01). Median time to complete the examination was 233.0 seconds (IQR 142) for both lungs, lowered from 254.0 seconds (IQR 129.5) (first trimester of study) to 205.5 seconds (IQR 88.5) (second trimester of the study). Significant findings on LUS were confirmed on pathological examination. CONCLUSIONS: LUS in awake rodents without shaving has been shown to be both feasible and safe and the images collected were of good quality and comparable to those obtained in anesthetized rats without bristles.

Effective and Safe Use of Glucocorticosteroids for Rescue of Late ARDS.

We describe a case of severe refractory hypoxemia requiring prolonged extra corporeal membrane oxygenation (ECMO) support in a case of postpartum acute respiratory distress syndrome (ARDS). The clinical course was marked by persistently poor lung compliance and several complications of ECMO, that is, significant hemolysis, hemothorax, and intracranial bleeding. We report marked improvement of lung mechanics and respiratory function, leading to accelerated separation from ECMO, following rescue administration of low dose methylprednisolone 24 days after the onset of ARDS. Corticosteroid treatment was safe and well tolerated. In contrast with the conclusions of the 2006 ARDS Network trial, our report establishes a case in support of the use of low dose methylprednisolone as a safe and effective rescue treatment option in selected subsets of patients with nonresolving ARDS.