Endovascular treatment under conscious sedation associated with worse outcomes than best medical treatmentDifferent types of anesthesia may impact stroke recovery outcomes

INTRODUCTION: Of the 3 published trials, only 1 showed possible efficacy of endovascular treatment (EVT) compared to best medical treatment (BMT) alone for medium or distal vessel occlusions (MDVO), whereas the others were neutral. Procedural conditions may affect the outcome. PATIENTS AND METHODS: This is a post-hoc analysis of the randomised, controlled DISTAL trial, conducted in 55 centers between 12/2021 and 7/2024. Patients with isolated MDVO within 24 hours of last seen well randomised to EVT plus BMT were treated under general anaesthesia (GA), conscious sedation (CS) or local anaesthesia (LA) at investigators' discretion. Endovascular treatment under different anaesthesia modalities was compared head-to-head, and to BMT alone. RESULTS: Among 491 patients included in the analysis, 224 received EVT plus BMT (108 GA, 64 LA, 52 CS) and 267 received BMT alone. Compared to BMT alone, EVT under CS was associated with worse 90-day modified Rankin Scale (median 2.5 vs 2.0; adjusted odds ratio [aOR] 0.51 [95% CI 0.29-0.90]), whereas no difference was observed between EVT under other anaesthesia modalities and BMT alone. Symptomatic intracranial haemorrhage occurred more frequently after EVT under GA compared to BMT alone (8.3% vs 2.6%; aOR 3.37 [95% CI, 1.22-9.66]). LA was associated with higher odds of better functional outcome (aOR 2.11 [95% CI, 1.09-4.12]) and lower mortality (aOR 0.28 [95% CI, 0.08-0.95]) compared to CS, whereas there was no difference to GA. DISCUSSION AND CONCLUSION: The lack of superiority of EVT plus BMT over BMT alone in DISTAL may not have been driven by anaesthesia modality.