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For mechanical thrombectomy stroke patients, consensus guidelines favoring general anesthesia over conscious sedation during the pandemic might need revisiting.

That was the argument presented at the virtual International Stroke Conference (ISC) in a debate over what should be the first-line strategy.

Conscious sedation minimizes delays to treatment, which have been a problem for COVID-19 patients, and provides at least as good outcomes, argued Tudor Jovin, MD, of the Cooper Neurological Institute in Cherry Hill, New Jersey.

He pointed to a of the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG) registries showing that 53% of thrombectomy patients who underwent general anesthesia during the pandemic had longer door to reperfusion times (138 vs 100 minutes) and nearly double the mortality risk, as well as lower functional independence scores at discharge.

Part of the problem might have been that "the majority of sites were not intubating most patients for [mechanical thrombectomy] prior to the pandemic, but rather did so following scientific society recommendations," the authors wrote in the Journal of NeuroInterventional Surgery.

Before the pandemic, U.S. centers' preference for general anesthesia versus sedation during mechanical thrombectomy was evenly split.

A more recent international survey found that half of centers reported some changes in anesthetic management during the pandemic.

Early in the pandemic, the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) released a consensus statement that called for individualization of the approach, but with a lower threshold for using general anesthesia than before.

At the time, patients had to be presumed positive for SARS-CoV-2 without rapid test availability. Intubating was seen as a means of protecting the healthcare team from exposure, noted Deepak Sharma, MD, of the University of Washington in Seattle and lead author on the SNACC guidelines.

However, competing recommendations from the (SVIN) in April emphasized conscious sedation as first line.

The greatest aerosol exposure risk was with emergent conversion from sedation to general anesthesia, and both organizations urged avoiding emergency intubation in the angio suite and having a lower threshold for starting with general anesthesia if there were any concerns about need for conversion.

Criteria of concern in a known or suspected COVID-19-positive patient differed between the two consensus statements, though. Unlike SVIN, SNACC included aphasic patients, those with posterior circulation or dominant hemisphere occlusions, and those with high stroke severity or low consciousness scores.

Posterior circulation stroke was a significant in a recent analysis of sedation practices from 2013 through mid-2020 at Grady Memorial Hospital in Atlanta.

But with a "very low" 1.6% conversion rate, "this is a tolerable risk," said Jovin.

He argued at the ISC session that conscious sedation should be the first-line strategy in mechanical thrombectomy when COVID status is unknown in order to minimize delays and optimize patient outcomes, among other advantages.

However, the more recent randomized trials using evidence from before the pandemic have swung the pendulum to a possibly better outcome with general anesthesia, Sharma noted.

A 2019 meta-analysis of the available single-center trials showed less disability at 3 months compared with procedural sedation.

At Sharma's center, the already low conversion rate dropped slightly during the pandemic period and the predominant approach to anesthesia flipped from conscious sedation to general anesthesia as well.

The SNACC statement noted that recommendations may need to be updated if a rapid diagnostic test for COVID-19 became available. And that's exactly what happened, said Jovin, an author of the SVIN .

Not only is it easier to quickly tell who has COVID-19, but as COVID-19 declines now that vaccination rates are increasing, this "should be taken into account in the way we approach the procedures for stroke," Jovin said.

He pointed out that for other percutaneous interventions, there are no recommendations for routine intubation of COVID-19 patients. "So why should we do it for stroke?"

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