Influence of the Anesthetic Regimen during the Endovascular Treatment of Intracranial Proximal Occlusions with a Large Infarct Core: A Post Hoc Analysis of the LASTE Trial Data

Background and Purpose: The optimal anesthetic regimen for the endovascular treatment (EVT) of stroke due to large vessel occlusion remains unclear. Patients with large infarct core on initial imaging constitute a specific subpopulation. The aim of this study was to investigate the impact of the anesthesia type during EVT on outcomes in this subpopulation. Materials and Methods: Data were extracted from the multicenter, randomized, controlled LASTE trial (n = 30 centers in France and Spain) that compared EVT plus best medical treatment versus best medical treatment alone in patients with large infarct core (ASPECTS = 0-5). In this post-hoc analysis, only patients who underwent EVT were included. Two study groups were defined: general anesthesia (GA), and conscious sedation and/or local anesthesia (CS-LA). The primary endpoint was the functional outcome, assessed with the modified Rankin Scale (mRS) at 3 months. Secondary endpoints included early neurological status, infarct extension at day 1, symptomatic intracranial hemorrhage, and mortality. Endpoints were investigated using univariate and multivariate analyses adjusted for pre-specified confounders. Results: For this post-hoc analysis, 159 patients were included: 45 in the GA group and 114 in the CS-LA group. The functional outcome at 3 months was not different between groups: median mRS score = 5 (IQR: 3-6) in the GA and 4 (IQR: 3-6) in the CS-LA group (adjusted OR = 0.78; 95% CI 0.52 - 1.18). However, in the GA group, the National Institutes of Health Stroke Scale score significantly worsened between admission and day 1 [mean difference= -3.8 (-6.6 to -1.0), p=0.007], infarct volume extension was more severe [mean difference: -26.5 ml (-50.2 to -2.9), p=0.028], and parenchymal hematoma was more frequently detected. Between-group differences in early neurological improvement, symptomatic intracranial hemorrhage, and mortality were not significant. Conclusion: In this post-hoc analysis of the LASTE trial data, we detected potential signals of a GA detrimental effect in patients with large infarct core on baseline imaging. Larger studies are necessary to confirm this finding.