不同麻醉方式对急性前循环缺血性卒中患者血管内治疗临床疗效影响的荟萃分析

Clinical efficacy of different anesthesia methods in patients with endovascular treatment for acute anterior circulation ischemic stroke:a meta-analysis

目的系统评价全身麻醉与清醒镇静对急性缺血性卒中血管内治疗患者的有效性与安全性。方法检索英文数据库PubMed、Embase与Cochrane,以及中文数据库万方医学与中国知网,搜集全身麻醉与清醒镇静影响急性前循环缺血性卒中血管内治疗临床疗效的随机对照试验,检索时间为建库至2022年7月14日;由2位研究员独立筛选文献、提取数据与评价偏倚风险;采用RevMan5.3软件进行荟萃分析。结果共纳入7项随机对照试验,包括923例患者,其中全身麻醉组461例,清醒镇静组462例。荟萃分析结果显示:与清醒镇静相比,全身麻醉显著改善了血管内治疗后3个月预后良好结局(改良Rankin量表评分≤2分)(OR=1.34,95%CI 1.01~1.78,P=0.04);全身麻醉亦显著提高了血管成功再通率(OR=1.87,95%CI 1.32~2.65,P<0.001)。两种麻醉方式对血管内治疗后病死率(OR=0.93,95%CI 0.66~1.29,P=0.65)、症状性颅内出血转化率(OR=0.88,95%CI 0.57~1.35,P=0.55)与介入操作相关并发症(OR=0.83,95%CI 0.50~1.36,P=0.46)均差异无统计学意义。然而,全身麻醉组发生平均动脉压较基线下降≥20%(OR=4.76,95%CI 1.49~15.19,P=0.008)与肺炎(OR=2.58,95%CI 1.51~4.39,P<0.001)的风险均显著高于清醒镇静组。结论与清醒镇静相比,急性缺血性前循环卒中患者全身麻醉下行血管内治疗可获得更好预后结局与更高血管成功再通率,但此种麻醉方式可增加术中血压变异幅度与肺炎发生率。

Objective To systematically evaluate the efficacy and safety of general anesthesia versus conscious sedation in patients with endovascular therapy for acute ischemic stroke.Methods Databases,including English databases PubMed,Embase and Cochrane,as well as Chinese databases Wan Fang Data and CNKI,were screened for randomized controlled trials(RCT)of general anesthesia versus conscious sedation on the effect of endovascular treatment for acute anterior circulation ischemic stroke.The searching period was from the establishment of databases to July 14,2022.Two researchers independently screened literatures,extracted data and evaluated the risk of bias.And meta-analysis was performed using RevMan5.3 software.Results A total of 7 RCTs involving 923 patients were included,with 461 in the general anesthesia group and 462 in the other.As the meta-analysis showing,general anesthesia could significantly improve the good outcomes(modified Rankin Scale score≤2)at 3 months after endovascular treatment in comparison with conscious sedation(OR=1.34,95%CI 1.01-1.78,P=0.04),and significantly increased the rate of successful revascularization(OR=1.87,95%CI 1.32-2.65,P<0.001).In addition,there were no statistically significant differences between the two groups in mortality(OR=0.93,95%CI 0.66-1.29,P=0.65),symptomatic intracranial hemorrhage(OR=0.88,95%CI 0.57-1.35,P=0.55)and intervention-related complications(OR=0.83,95%CI 0.50-1.36,P=0.46).However,general anesthesia was associated with higher risk for both 20%reduction in mean arterial pressure(OR=4.76,95%CI 1.49-15.19,P=0.008)and pneumonia(OR=2.58,95%CI 1.51-4.39,P<0.001).Conclusions Compared with conscious sedation,endovascular treatment under general anesthesia in patients with acute anterior circulation ischemic stroke may contribute to better outcomes and higher successful revascularization.However,this method will lead to the risk of blood pressure variability and the incidence of pneumonia.