Perioperative Medicine

ABSTRACT
Background: It is speculated that the anesthetic strategy during endovas-
cular therapy for stroke may have an impact on the outcome of the patients.

General Anesthesia versus The authors hypothesized that conscious sedation is associated with a better
functional outcome 3 months after endovascular therapy for the treatment of

Sedation, Both with

stroke compared with general anesthesia.
Methods: In this single-blind, randomized trial, patients received either a
Hemodynamic Control, standardized general anesthesia or a standardized conscious sedation. Blood
pressure control was also standardized in both groups. The primary outcome

during Intraarterial measure was a modified Rankin score less than or equal to 2 (0 = no symp-

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toms; 5 = severe disability) assessed 3 months after treatment. The main

Treatment for Stroke: The secondary outcomes were complications, mortality, reperfusion results, and
National Institutes of Health Stroke Scores at days 1 and 7.

GASS Randomized Trial Results: Of 351 randomized patients, 345 were included in the analysis. The
primary outcome occurred in 129 of 341 (38%) of the patients: 63 (36%) in
Axelle Maurice, M.D., François Eugène, M.D., the conscious sedation group and 66 (40%) in the general anesthesia group
Thomas Ronzière, M.D., Jean-Michel Devys, M.D., (relative risk, 0.91 [95% CI, 0.69 to 1.19]; P = 0.474). Patients in the general
anesthesia group experienced more intraoperative hypo- or hypertensive epi-
Guillaume Taylor, M.D., Aurélie Subileau, M.D.,
sodes, while the cumulative duration was not different (mean ± SD, 36 ± 31
Olivier Huet, M.D., Ph.D., Hakim Gherbi, M.D.,
vs. 39 ± 25 min; P = 0.079). The time from onset and from arrival to puncture
Marc Laffon, M.D., Ph.D., Maxime Esvan, M.Sc.,
were longer in the general anesthesia group (mean difference, 19 min [i.e.,
Bruno Laviolle, M.D., Ph.D., Helene Beloeil, M.D., Ph.D., for
−00:19] [95% CI, −0:38 to 0] and mean difference, 9 min [95% CI, −0:18
the GASS (General Anesthesia versus Sedation for Acute to −0:01], respectively), while the time from onset to recanalization was sim-
Stroke Treatment) Study Group and the French Society of ilar in both groups. Recanalization was more often successful in the general
Anesthesiologists (SFAR) Research Network* anesthesia group (144 of 169 [85%] vs. 131 of 174 [75%]; P = 0.021). The
Anesthesiology 2022; 136:567–76 incidence of symptomatic intracranial hemorrhage was similar in both groups.
Conclusions: The functional outcomes 3 months after endovascular
treatment for stroke were similar with general anesthesia and sedation. Our
EDITOR’S PERSPECTIVE results, therefore, suggest that clinicians can use either approach.

What We Already Know about This Topic (ANESTHESIOLOGY 2022; 136:567–76)

• Intraarterial endovascular thrombectomy is considered as a stan-

dard of care for patients with ischemic stroke caused by a large
vessel occlusion in the anterior cerebral circulation
• The question whether periprocedural conscious sedation versus
general anesthesia influences neurologic outcome in these patients
E ndovascular therapy in addition to the medical treat-
ment is now the standard of care for select patients
who had a stroke caused by a large vessel occlusion in the
is incompletely explored anterior circulation.1 The two main factors associated with
What This Article Tells Us That Is New a good outcome are time, namely the rapidity of the treat-
ment,2 and hemodynamic conditions.3,4
• In this single-blind, randomized trial including patients with large
In this context, the best anesthetic strategy during the
vessel occlusion of the anterior cerebral circulation, standardized
endovascular treatment is still a matter of debate. While
general anesthesia and standardized conscious sedation for endo-
vascular therapy resulted in comparable modified Rankin scores allowing for immobility, cerebral protection, and airway
when evaluated 3 months after intervention control, general anesthesia can delay the endovascular treat-
• These observations suggest that the functional outcome 3 months ment and, if not controlled, can be associated with hemo-
after endovascular treatment for ischemic stroke is comparable for dynamic instability. On the other hand, conscious sedation
general anesthesia and sedation is faster and allows for neurologic assessment during a

This article is featured in “This Month in Anesthesiology,” page A1. This article has an audio podcast. This article has a visual abstract available in the online version.
Submitted for publication July 30, 2021. Accepted for publication January 10, 2022. From the Anesthesia and Intensive Care Department (A.M.), University Rennes; the Radiology
Department (F.E.), and Neurology Department (T.R.); and the Clinical Pharmacology Department (M.E., B.L.) and the Anesthesia and Intensive Care Department (H.B.), Center
of Clinical Investigation, Inserm, Rennes Teaching Hospital, Rennes, France; the Anesthesia Department, Rothschild Hospital and Foundation, Paris, France (J.-M.D., G.T.); the
Anesthesia and Intensive Care Department, University Brest, Brest Teaching Hospital, Brest, France (A.S., O.H.); and the Anesthesia and Intensive Care Department, University Tours,
Tours Teaching Hospital, Tours, France (H.G., M.L.).
*Members of the GASS (General Anesthesia versus Sedation for Acute Stroke Treatment) Study Group and French Society of Anesthesiology (SFAR) Research Network are listed
in the appendix.
Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved. Anesthesiology 2022; 136:567–76. DOI: 10.1097/ALN.0000000000004142
ANESTHESIOLOGY, V 136 • NO 4 April 2022 567
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<zdoi;. DOI: 10.1097/ALN.0000000000004142>
 PERIOPERATIVE MEDICINE

procedure, but thrombectomy can be less safe for the neu- or if, at the end of the trial [end of patient follow-up], the
roradiologist because of patient movement. More hemo- patient was still not able to understand the information and
dynamic stability was reported in retrospective studies.5–7 provide consent, the data collected in the study could be
Studies published thus far report controversial results: con- used if a relative gave consent or if the relative could not
scious sedation is associated with better outcomes8–10 in be reached after several attempts.) An independent data and
some studies; the two techniques have similar outcomes in safety monitoring board oversaw the study conduct and
other studies.11–14 A meta-analysis including the first three reviewed blinded safety data.
randomized controlled trials on the subject recommended
systematic study of the relationship that stroke and Patients
treatment-related variables have with outcomes after endo-
We studied patients older than 18 yr who had given written
vascular therapy.15 The Diffusion and Perfusion Imaging
informed consent and who were admitted to a participating
Evaluation for Understanding Stroke Evolution (DEFUSE)

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center for occlusion of a large vessel in the anterior cerebral
study found that patients who underwent thrombec-
circulation, admitted for endovascular therapy,17 and affil-
tomy with conscious sedation had a higher likelihood of
iated with a social security system. Noninclusion criteria
functional independence at 90 days and a lower National
included patients who were already intubated and mechan-
Institutes of Health (Bethesda, Maryland) Stroke Score at
ically ventilated before inclusion in the study; had intracere-
24 h.10 However, the choice between general anesthesia and
bral hemorrhage associated with the ischemic stroke; were
conscious sedation was left to the discretion of the team,
contraindicated for conscious sedation (e.g., Glasgow coma
and the protocols were neither detailed nor standardized.10
scale less than 8; agitation preventing patient from staying
Indeed, previous studies did not focus on anesthetic proto-
still during the procedure; deglutition disorder) or succinyl-
col and intraoperative hemodynamic control.16 Moreover,
choline (e.g., hyperkalemia, body mass index greater than
the difference between profound conscious sedation and
35 kg/m2); had known allergies to any of the drugs used
light general anesthesia has not always been clearly identi-
for anesthesia or to any of their excipients, uncontrolled
fied.11 A randomized trial including a protocolized aspect of
hypotension, or life-threatening comorbidity; could not
hemodynamic control has been frequently recommended.16
walk; had a previous stroke; were pregnant or breastfeeding;
To address this uncertainty, we conducted the General
were legally protected adults (e.g., under judicial protection,
Anesthesia versus Sedation for Acute Stroke Treatment
guardianship, or supervision); or were persons deprived of
(GASS) trial to evaluate the hypothesis that conscious seda-
their liberty).
tion would be associated with better clinical outcomes as
measured by modified Rankin score 3 months after the
procedure.
Randomization and Interventions
Patients underwent randomization in a 1:1 ratio to
Materials and Methods undergo either general anesthesia or conscious sedation.
Randomization was centralized and computer generated,
Study Design and each patient was given a unique randomization number
(patient code). It was a block-randomization stratified by
This was an investigator-initiated, prospective, multicenter,
center, the National Institutes of Health Stroke Scores of
parallel-group, single-blind, randomized, controlled, supe-
Health Stroke Score (less than or equal to 14 or greater than
riority trial conducted in four centers in France (Rennes
14), and the administration (or not) of IV thrombolysis.
Hospital  [Rennes, France], Brest Hospital  [Brest, France],
Investigators proposed participation in the study to patients
Tours Hospital  [Tours, France], and the Rothschild
on arrival at the stroke center, obtained written informed
Foundation in Paris [Paris, France] [clinical trial registration
consent (or proceeded to an emergency procedure), and
No. NCT02822144; July 4, 2016; principal investigator,
randomized patients as close as possible to the endovas-
Helene Beloeil]).The rationale and design of the study have
cular therapy. Treatment assignments were concealed from
been reported previously.17 The study was approved for all
patients, nonmedical research staff, the statistician, and
centers by a central ethics committee (Comité de Protection
the data and safety monitoring committee. Although staff
des Personnes Poitiers Ouest III, June 13,  2016; National
members who collected data during surgery were aware
Agency for Drug Safety: March 8, 2016, No. 160454A-31).
of group assignments, outcome assessors were not aware of
Written informed consent was obtained from all partici-
these assignments throughout the study.
pating patients or relatives either before inclusion in the
study or after an emergency procedure for inclusion. (The
patient was included and randomized before his/her or a Protocol
relative’s consent, and informed as soon as his/her condition Previously published trial protocol17 involved the standard-
allowed information and his/her consent was sought for the ization of anesthesia induction and maintenance. Patients
possible continuation of the research and/or the use of his/ in the general anesthesia group received etomidate (0.25
her data. If the patient died before consent was obtained to 0.4 mg/kg) and then target-controlled infusion propofol

568 Anesthesiology 2022; 136:567–76 Maurice et al.

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 General Anesthesia or Sedation for Stroke

(maximum target, 4 μg/ml) and target-controlled infu- An additional exploratory analysis of the primary end-
sion remifentanil (0.5 to 4 ng/ml) and succinylcholine point was performed to assess treatments effects according
(1 mg/kg). Muscle relaxant reinjection was authorized as to baseline National Institutes of Health Stroke Score (less
needed. Patients in the conscious sedation group received than or equal to 14 or greater than 14) and the administra-
target-controlled infusion remifentanil (maximum target, tion or not of IV thrombolysis.
2 ng/ml) and local anesthesia with lidocaine 10 mg/ml Secondary Outcomes.  Secondary outcomes were time from
(maximum, 10 ml). Oxygen was administered only if oxy- stroke onset to groin puncture; time from arrival in the
gen saturation measured by pulse oximetry was less than stroke center to groin puncture; technical failure of the
or equal to 96%. Respiratory rate and capnography were endovascular treatment (defined as failure of arterial punc-
monitored. Conversion from conscious sedation to general ture or catheterization); reperfusion results evaluated by
anesthesia was also standardized and allowed in the fol- the neuroradiologist (good reperfusion corresponded to a
lowing situations: agitation or restlessness not allowing the modified treatment in cerebral ischemia scale score of 2b

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endovascular treatment; vomiting not allowing the endo- or 3); National Institutes of Health Stroke Scale score at
vascular treatment; Glasgow coma scale less than 8; and/or day 1 (i.e., day after the endovascular treatment) and day 7
deglutition disorders, severe hypoxemia with oxygen satu- (or the day the patient left the hospital if scheduled before
ration measured by pulse oximetry at less than 96% with day 7); complications during the procedure (dissection, rup-
oxygen being delivered via high-concentration mask (max- ture of the artery, thrombus in another territory); mortality
imum, 10 l/min), respiratory rate greater than 35/min, and/ rate 3 months after the endovascular treatment; number of
or clinical signs of respiratory exhaustion. hypo- or hypertensive events during the procedure and the
In both groups, intraoperative dose changes were left to first 24 h after the procedure (hypotension was defined as
the anesthesiologist in charge of the patient. The mainte- systolic blood pressure less than 140 mmHg or a decrease
nance of blood pressure during the endovascular treatment in the mean arterial blood pressure of 40% or more; hyper-
was standardized. IV norepinephrine was administered tension was defined as systolic blood pressure greater than
in order to maintain blood pressure within the recom- 185 mmHg or diastolic blood pressure greater than 110
mended range (i.e., systolic blood pressure between 140 mmHg); number of patients who received norepinephrine;
and 185 mmHg; diastolic blood pressure less than 110 and number of conversions from conscious sedation to gen-
mmHg). A decrease of more than 25% of the mean blood eral anesthesia.
pressure was not tolerated. Postoperatively, blood pressure
targets were defined as a systolic blood pressure less than Statistical Analysis
180 mmHg, diastolic blood pressure less than 110 mmHg,
Sample size was calculated as a 30% rate of patients with
and mean arterial blood pressure greater than 65 mmHg.
a good prognosis (defined as modified Rankin score of 2
In case of a Thrombolysis in Cerebral Ischemia grade 2a
or less) after endovascular therapy under general anesthe-
or lower, the objective was a mean arterial blood pressure
sia12 and 45% after endovascular treatment under conscious
greater than 75 mmHg. Intraoperative blood pressure was
sedation. Therefore, 166 patients per group were needed to
continuously and noninvasively monitored with a cuff.
have 80% power at a two-sided α level of 0.05. To allow for
The frequency of blood pressure measurements was not
potential unevaluable patients, the number of patients to be
standardized postoperatively. In order to reach these blood
enrolled was increased to 350 patients.
pressure targets, norepinephrine was administered via a
Statistical analysis was conducted on an intention-to-
continuous infusion in a dedicated IV line and diluted at
treat basis. A first overall descriptive analysis and analysis by
250 μg/ml. The dose administered was adapted to blood
group was performed. This consisted of separate estimates:
pressure.
numbers and percentages for qualitative variables, and means
A systematic immediate post−endovascular treatment
± SD or medians and interquartile intervals for quantitative
cone beam computed tomography scan was performed for
variables.The primary endpoint was compared between the
all patients. Decisions about all other aspects of patient care
two groups with the chi-square test. Two interim analyses
were performed according to the expertise of the staff at
after inclusion of one third and two thirds of patients and
each center and to routine clinical practice to minimize
one final analysis were planned. Stopping rules were the
interference with the trial intervention.
α-spending function with the O’Brien–Fleming boundary.
The cumulative values of α for each analysis were 0.00021 at
Measurements first analysis; 0.01202 at second analysis; and 0.04626 at final
Primary Outcome.  The primary outcome was the neuro- analysis (nTerim, V.1.1; Statistical Solutions Ltd., Ireland).
logic outcome assessed by modified Rankin score between The trial would have been stopped early if the significance
2 and 6 months after the endovascular treatment. Success of the chi-square test was below these α values. For the
was considered as a modified Rankin score of 2 or less. analysis of the other endpoints, an independent sample t test
The modified Rankin score was assessed by trained research or Mann–Whitney U test, if necessary, was used to com-
nurses blinded to the randomization group. pare continuous or discrete data, and a chi-square or Fisher

Anesthesiology
Maurice et al. 2022; 136:567–76 569
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 PERIOPERATIVE MEDICINE

exact test, if necessary, was used to compare categorical data group (P = 0.288); modified Rankin scores were evaluated
between two groups at inclusion. Except for the interim after 6 months in 6% of patients. Specifically, median time
analyses, a P value less than 0.05 was considered as signif- of assessment of the modified Rankin score was 111 days
icant for all analyses. Planned subgroup analyses were per- (interquartile range, 95 to 132) for both patients receiving
formed on the primary endpoint according to the National conscious sedation and patients receiving general anesthesia
Institutes of Health Stroke Scale (score less than or equal to (interquartile range, 92 to 130), with no statistical difference
14 or greater than 14) and IV thrombolysis. Sensitivity anal- (P = 0.755).
yses were performed on the primary endpoint according to Results were similar when adjusted to baseline National
the date of modified Rankin score collection (collection Institutes of Health Stroke Scale score (less than or equal to
before 6 months; collection before 4 months). Missing val- 14 [relative risk, 0.91 {95% CI, 0.64 to 1.31}; P = 0.858])
ues were imputed on neither primary endpoint (because or administration of IV thrombolysis (relative risk, 0.91
the proportion of missing data was less than 2%) nor on [95% CI, 0.65 to 1.28]; P = 0.942).

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secondary endpoints. After examination of the data, adjust-
ment for confounding variables was not necessary. Analyses Secondary Outcomes
were performed using SAS software (V.9.4; USA).
Patients in the general anesthesia group experienced more
intraoperative hypotension and hypertension episodes
Results (table 3). They also received statistically significantly more
vasoactive drugs. As shown in table  3, epinephrine was
Patients administered to some patients despite the protocol speci-
Of the 3,472 screened patients between September 2016 fying that hypotension had to be treated with norepineph-
through June 2020 (408 at Brest Hospital; 920 at Rennes rine. The cumulative duration of hypotension was similar
Hospital; 868 at Tours Hospital; 1,276 at Rothschild in both groups (table  3). The time from onset and from
Foundation in Paris), 351 underwent randomization and arrival to puncture were longer in the general anesthesia
345 (conscious sedation, 177; general anesthesia, 174) were group (table 3). The time from onset to recanalization was
included in the analysis (fig. 1). Data on primary outcome similar in both groups (table 3). Recanalization (a modified
were available for 176 patients in the conscious sedation Treatment in Cerebral Infarction score of 2b to 3) was more
group and 169 in the general anesthesia group. often successful in the general anesthesia group (table  3).
The demographic, clinical, and stroke characteristics of Twenty-one patients in the conscious sedation group did
the two groups are presented tables 1 and 2.They were sim- not benefit from endovascular treatment: 13 (65%) expe-
ilar except for two preoperative treatments. More patients rienced failure of the endovascular treatment; arterial
were treated for hypertension (with conversion enzyme occlusion was not found during angiography for 7 patients
inhibitors) and with oral anticoagulants in the conscious (35%); and the reason was not reported for 1 patient. Fifteen
sedation group compared with the general anesthesia group patients did not benefit from endovascular treatment in the
(table  1). Endovascular treatment was realized in 88% of general anesthesia group: 4 (27%) experienced failure of
patients in the conscious sedation group and 91% of patients the endovascular treatment; and in 11 (73%) patients, the
in the general anesthesia group (P = 0.353). Two patients arterial occlusion was not found during angiography. The
in the conscious sedation group and three in the general technical failure rate was low (17 of 345 [4.9%]), but signifi-
anesthesia group received a second endovascular treatment. cantly different: 13 of 176 (7.3%) in the conscious sedation
Conscious sedation was converted into general anesthesia group and 4 of 169 (2.3%) in the general anesthesia group
for eight patients (4%) for the following reasons: agitation (P = 0.044). The rate of symptomatic intracranial hemor-
(n = 4); vomiting (n = 1); Glasgow coma scale less than 8 rhage was similar in both groups. (table  3). Finally, results
(n = 1); hypoxemia (n = 1); or other (failure of catheter, were similar within all four centers.
respiratory arrest; n = 3).
Discussion
Primary Outcome In this multicenter, randomized trial, conscious sedation or
A favorable neurologic outcome with a modified Rankin general anesthesia during endovascular therapy for stroke
score of 2 or less at 3 months after treatment was seen in resulted in a similar outcome when modified Rankin scores
129 (38%) of the 341 patients; 63 (36%) patients in the con- were evaluated at 3 months. There was a greater incidence
scious sedation group and 66 (40%) in the general anesthesia of technical failure of endovascular therapy in the conscious
group had favorable outcomes with no statistical differences sedation group, while recanalization was better in the gen-
(relative risk, 0.91 [95% CI, 0.69 to 1.19]; P = 0.474; fig. 2). eral anesthesia group. Patients experienced more episodes
Modified Rankin scores were evaluated between 2 and of hyper- and hypotension in the general anesthesia group;
6 months after treatment in 94% of patients in the con- however, the cumulative duration of hypotension was sim-
scious sedation group and 96% in the general anesthesia ilar in both groups.

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Fig. 1.  Flow of participants through the study.

The first three randomized trials comparing general In the Anesthesia During Stroke (AnStroke) trial, Löwhagen
anesthesia and sedation reported similar outcomes with et al.12 also reported no differences between the two techniques
conscious sedation or general anesthesia in a total of 368 on outcome at 3 months after endovascular treatment using
patients.11–13 For the Sedation vs. Intubation for Endovascular a detailed anesthesia protocol; however, the study was a sin-
Stroke Treatment (SIESTA) trial, Schönenberger et al.11 gle-center study that included only 90 patients. In the General
reported that the single-center study outcome at 24 h and or Local Anesthesia in Intraarterial Therapy (GOLIATH) trial,
3 months was similar for both techniques; functional out- Simonsen et al.13 used an identical design with infarct growth
come at 3 months was only a secondary outcome. However, as the primary endpoint and reported no differences; however,
the anesthesia protocol was not detailed, and the definitions clinical outcome at 90 days, tested as a secondary endpoint,
of general anesthesia and conscious sedation were not clearly was better in patients who benefitted from general anesthesia.
stated. Indeed, the design allowed patients benefitting from A post hoc analysis showed that safety of endovascular treat-
conscious sedation to receive analgesics and/or sedatives if ment and reperfusion was also similar under general anesthesia
necessary, which could then transform the sedation into or conscious sedation.14 Meta-analyses have reported contro-
light general anesthesia. versial results. One meta-analysis analyzing the pooled data of

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 PERIOPERATIVE MEDICINE

Table 1.  Characteristics of Patients

Standardized
Characteristic Conscious Sedation General Anesthesia Difference (95% CI)

Age, yr* 72.6 ± 12.3 70.8 ± 13.0 –0.13 (–0.35 to 0.07)

Sex, female* 77 (44) 80 (47) –0.07 (–0.28 to 0.14)
Body mass index, kg/m2† 26 ± 4 26 ± 5 0.02 (–0.19 to 0.23)
Heart rate, beats/min‡ 77 ± 18 81 ± 20 0.21 (–0.01 to 0.42)
Arterial blood pressure, mmHg§
 Systolic 151 ± 24 147 ± 27 –0.18 (–0.39 to 0.04)
 Diastolic 83 ± 15 81 ± 18 –0.11 (–0.32 to 0.10)
 Mean 106 ± 15 103 ± 19 –0.16 (–0.37 to 0.05)

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Medical history*
  Atrial fibrillation 55 (32) 52 (31) –0.01 (–0.22 to 0.21)
 Hypertension 124 (70) 97 (57) –0.27 (–0.49 to –0.06)
  Diabetes mellitus 27 (15) 22 (13) –0.07 (–0.28 to 0.14)
  Myocardial infarction 8 (5) 4 (2) –0.12 (–0.33 to 0.09)
 Peripheral arterial disease 14 (8) 9 (5) –0.11 (–0.32 to 0.11)
 Previous stroke* 23 (13) 22 (13) –0.00 (–0.21 to 0.21)
  Antihypertension treatment* 132 (75) 107 (64) –0.24 (–0.46 to –0.03)
   Conversion enzyme inhibitors/angiotensin-converting enzyme inhibitors 87 (66) 62 (58) –0.16 (–0.42 to 0.09)
  β-Blocker 82 (62) 72 (67) 0.11 (–0.15 to 0.36)
 Anticoagulant* 40 (23) 24 (14) –0.22 (–0.43 to –0.01)
   Vitamin K antagonist 20 (50) 10 (42) –0.17 (–0.67 to 0.34)
  Rivaroxaban/apixaban/dabigatran 16 (40) 10 (42) 0.03 (–0.47 to 0.54)
  Heparin 2 (5) 4 (10) 0.38 (–0.13 to 0.89)
 Antiaggregant* 49 (28) 50 (30) –0.22 (–0.43 to –0.01)

Data are presented as mean ± SD for continuous variables and frequency (%) for categorical variables. Heart rate and blood pressure were assessed during the preoperative con-
sultation.
*Data were available for 176 patients in the conscious sedation group and 169 in the general anesthesia group. †Data were available for 166 patients in the conscious sedation group
and 156 in the general anesthesia group. ‡Data were available for 155 patients in the conscious sedation group and 151 in the general anesthesia group. §Data were available for
165 patients in the conscious sedation group and 154 in the general anesthesia group.

Table 2.   Stroke Characteristics

Characteristic Conscious Sedation General Anesthesia

Time from stroke onset to admission in emergency department, min* 88 ± 53 89 ± 57
Time from stroke onset to admission in stroke center, min* 266 ± 79 257 ± 70
National Institutes of Health Stroke Scale score on admission† 16 ± 5 16 ± 6
Intracranial arterial occlusion ‡
  Intracranial internal carotid artery only 14 (8) 23 (14)
  First middle cerebral artery segment only 109 (62) 99 (59)
  Second middle cerebral artery segment only 21 (12) 19 (11)
  Other segment 1 (0.6) 0 (0)
  Tandem occlusion 31 (18) 28 (17)
Localization of stroke in left hemisphere ‡ 90 (51) 84 (50)
IV thrombolysis‡ 114 (65) 111 (66)

Data are presented as mean ± SD for continuous variables and frequency (%) for categorical variables.
*Data were available for 155 patients in the conscious sedation group and 148 in the general anesthesia group.  †Data were available for 173 patients in the conscious sedation group
and 167 in the general anesthesia group. ‡Data were available for 176 patients in the conscious sedation group and 169 in the general anesthesia group.
IV, intravenous.

seven trials8 reported that outcome at 3 months was worse opposing conclusion, with general anesthesia being associated
with general anesthesia; however, some trials included in this with less disability at 3 months; however, as noted, the three
meta-analysis did not randomize the choice between general included trials were single-center, and outcome at 3 months
anesthesia and conscious sedation. A second meta-analysis18 was not the primary outcome for two of three.
consisting of data analysis of the first three randomized, con- The DEFUSE study found that patients who under-
trolled trials (SIESTA, AnStroke, and GOLIATH) reported an went thrombectomy with conscious sedation experienced

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Fig. 2.  Neurologic outcome expressed as modified Rankin score.

increased likelihood of functional independence at 90 days control for both groups, patients in the general anesthesia
and lower National Institutes of Health Stroke Scale scores group experienced more episodes of hypo- and hyperten-
at 24 h10; however, the choice between general anesthesia sion; however, the cumulative duration of hypotension and
and conscious sedation was left to the discretion of the team, outcome at 3 months was similar in both groups. Proper
and protocols were neither detailed nor standardized.10 The attention to cumulative time within preset hemodynamic
difference between profound conscious sedation and light ranges is possible with either technique. Indeed, general
general anesthesia has not always been clearly identified in anesthesia associated with a standardized and well-known
previous studies.11 Recent data from the German Stroke hemodynamic control protocol was as safe as conscious
Registry favored conscious sedation over general anesthesia sedation.
with a better functional outcome9; however, neither general One factor alone (i.e., type of anesthesia or hemody-
anesthesia and conscious sedation protocols nor intrapro- namics) is probably not defining the functional outcome
cedural hemodynamic management was reported. Unlike at 3 months, however, and a combination of many factors
most previous studies, a standardized anesthesia protocol is probably involved. In our study, despite the incidence of
was applied in both groups in our study and resulted in a technical failure of endovascular therapy being greater in
similar outcome evaluated via modified Rankin score at 3 the conscious sedation group while recanalization was bet-
months. ter in the general anesthesia group, the outcome was similar
Moreover, the hemodynamic control during the proce- in both groups. In other words, patients in the conscious
dure was also standardized in our study despite the lack sedation group experienced more technical failure, while
of clear and detailed recommendations in the literature. patients in the general anesthesia group experienced more
European guidelines call for avoiding excessive systolic hypo- and hypertensive episodes and better recanalization,
blood pressure drops during thrombectomy without any but these differences did not influence outcome.
further details.19 A post hoc analysis of the GOLIATH study20 There are several limitations to our study. First, the pri-
reported that hemodynamics during the procedure did not mary outcome was scheduled to be assessed 3 months after
have any impact on the outcome after endovascular treat- treatment; however, it was actually assessed in a wider time-
ment for stroke. A post hoc analysis of the first three random- frame (between 2 and 6 months after treatment) for logis-
ized trials (SIESTA, AnStroke, and GOLIATH), however, tic reasons. Second, a systematic, day 1, post–endovascular
reported that mean arterial blood pressure less than 70 treatment computed tomography scan or magnetic reso-
mmHg for more than 10 min or greater than 90 mmHg nance image assessing Alberta Stroke Program Early CT
for more than 45 min were both critical and associated with (ASPECT) score was not originally scheduled17 because
poor functional outcome after endovascular treatment for it was not standard practice at the time of study design.
stroke.21 In our study, despite a standardized hemodynamic The systematic post–endovascular treatment cone-beam

Anesthesiology
Maurice et al. 2022; 136:567–76 573
Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 PERIOPERATIVE MEDICINE

Table 3.  Secondary Outcomes

Mean/Median/Risk
Conscious Sedation General Anesthesia Difference (95% CI) P Value

Time from stroke onset to groin puncture, min* 248 ± 92 269 ± 85 −20 (−39 to −01) 0.040
Time from arrival at stroke center to groin puncture, min* 60 ± 39 69 ± 44 −10 (−19 to −01) 0.037
Time from stroke onset to recanalization, min* 307 ± 87 320 ± 96 −13 (−33 to 07) 0.203
Modified Thrombolysis in Cerebral Ischemia grade 2b–3† 131 (75) 144 (85) −10 (−18 to −2) 0.021
National Institutes of Health Stroke Scale score
  Day 1 11 ± 7 11 ± 9 0 (−2 to 1) 0.623
  Day 7 8 ± 7 8 ± 7 −1 (−2 to 1) 0.417
Arterial complications‡ 13 (8) 9 (5) 2 (−3 to 7) 0.418

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 Perforation 9 (5) 7 (4) 1 (−4 to 6) 0.652
 Dissection 3 (2) 2 (1) 0 (−2 to 3) > 0.999
  Clot migration 1 (0.6) 0 (0) 1 (−1 to 2) > 0.999
Symptomatic intracerebral hemorrhage 42 (24) 37 (22) 2 (−7 to 11) 0.642
Mortality at 3 months§ 28 (16) 31 (19) −3 (−11 to 5) 0.514
Remifentanil, ng/ml∥ 1.4 ± 0.7 2.6 ± 1.1 −1.2 (−1.5 to −1.0) < 0.0001
Intraoperative ephedrine administration# 9 (5) 36 (22) −17 (−24 to −9) < 0.0001
Intraoperative ephedrine doses, mg# 13 ± 6 13 ± 9 −1 (−6 to 6) 0.986
Norepinephrine** 99 (57) 157 (95) −37 (−46 to −30) < 0.0001
Duration of norepinephrine administration, h** 1:00 (0:35 to 2:05) 1:27 (0:50 to 3:00) −00:18 (−00:35 to 00:00) 0.024
Norepinephrine doses >1 mg/h** 25 (26) 74 (47) −22 (−34 to −10) 0.0005
Intraoperative hemodynamics††
  Episode(s) of hypotension 1 (1 to 2) 2 (1 to 2) 0 (−1 to 0) 0.001
  ≥ 1 episode of hypotension 129 (77) 163 (100) −23 (−30 to −17) < 0.0001
  Cumulative duration of hypotension, min 36 ± 31 39 ± 25 −2 (−9 to 4) 0.079
  Episode(s) of hypertension 0 (0 to 0) 0 (0 to 1) 0 (0 to 0) 0.033
  ≥ 1 episode of hypertension 33 (20) 49 (31) −11 (−20 to −1) 0.030
  Cumulative duration of hypertension, min 8 ± 7 11 ± 12 −1 (−5 to 4) 0.739
  Intraoperative antihypertension treatment 22 (12) 19 (11) −1 (−6 to 8) 0.749
Hemodynamics within first 24 h‡‡
  Episode(s) of hypotension 2 (1 to 3) 2 (1 to 2) 0 (0 to 1) 0.480
  ≥ 1 episode of hypotension 36 (31) 38 (33) −2 (−14 to 10) 0.744
  ≥ 1 episode of hypertension 30 (26) 34 (29) −4 (−15 to 8) 0.530
  Cumulative duration of hypotension, min 218 ± 200 228 ± 324 −11 (−136 to 115) 0.867
  Episode(s) of hypertension 1.5 (1 to 2) 1 (1 to 2) 0 (0 to 0) 0.105
  Cumulative duration of hypertension, min 81 ± 83 71 ± 74 10 (−29 to 49) 0.611

Data are presented as mean ± SD for continuous variables, frequency (%) for categorical variables, or median (interquartile range). Hypotension was defined as systolic blood pressure
< 140 mmHg, or mean blood pressure drop ≥ 40%. Hypertension was defined as systolic blood pressure > 185 mmHg or diastolic blood pressure > 110 mmHg. A modified Thrombol-
ysis in Cerebral Ischemia grade of 2b to 3 was considered successful recanalization.
*Data were available on 168 patients in the conscious sedation group and 163 in the general anesthesia group. †Data were available on 174 patients in the conscious sedation group
and 169 in the general anesthesia group. ‡Data were available on 170 patients in the conscious sedation group and 165 in the general anesthesia group. §Data were available on 175
patients in the conscious sedation group and 166 in the general anesthesia group. ∥Data were available on 170 patients in the conscious sedation group and 157 in the general anes-
thesia group. #Data were available on 172 patients in the conscious sedation group and 165 in the general anesthesia group. **Data were available on 173 patients in the conscious
sedation group and 165 in the general anesthesia group. ††Data were available on 168 patients in the conscious sedation group and 163 in the general anesthesia group. ‡‡Data were
available on 117 patients in the conscious sedation group and 116 in the general anesthesia group.

computed tomography used during the study did not have general anesthesia group experienced more hypo-/hyper-
enough spatial resolution to evaluate day 1 ASPECT scores, tensive episodes and better recanalization, but these differ-
only immediate postoperative bleeding transformation of ences did not influence outcome. From a practical point of
the stroke. Third, the number of patients with good func- view, physicians may favor general anesthesia because the
tional outcome was lower and mortality rate was higher outcome is similar to that of conscious sedation, which is
in our study when compared with previous studies, espe- associated with more technical failure and may be less com-
cially with the Trial and Cost Effectiveness Evaluation of fortable for the neuroradiologist. General anesthesia could
Intraarterial Thrombectomy in Acute Ischemic Stroke also be associated with complications like difficult airway
(THRACE) study22; however, our study’s population was management. The choice between the two techniques
also older than the THRACE study’s. should therefore be personalized to each patient.
In summary, among patients undergoing endovascular
treatment for stroke, the functional outcome at 3 months Research Support
was similar in patients receiving conscious sedation or gen- The GASS trial was supported by funding from the
eral anesthesia. Patients in the conscious sedation group French Ministry of Health (Paris, France; National Clinical
experienced more technical failures, while patients in the Research Hospital Program, 2015). The funding sources

574 Anesthesiology 2022; 136:567–76 Maurice et al.

Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 General Anesthesia or Sedation for Stroke

had no role in the trial design, trial conduct, data handling, 5. Abou-Chebl A, Yeatts SD, Yan B, Cockroft K, Goyal
data analysis, or writing and publication of the manuscript. M, Jovin T, Khatri P, Meyers P, Spilker J, Sugg R,
Wartenberg KE, Tomsick T, Broderick J, Hill MD:
Competing Interests Impact of general anesthesia on safety and outcomes in
Dr. Beloeil received speaking fees from AbbVie (Chicago, the endovascular arm of Interventional Management
Illinois) and Aspen Pharmacare (Durban, South Africa) and of Stroke (IMS) III trial. Stroke 2015; 46:2142–8
is a member of an expert board for Orion Pharma (Espoo, 6. Berkhemer OA, van den Berg LA, Fransen PS, Beumer
Finland). The other authors declare no competing interests. D, Yoo AJ, Lingsma HF, Schonewille WJ, van den Berg
R, Wermer MJ, Boiten J, Lycklama À Nijeholt GJ,
Reproducible Science Nederkoorn PJ, Hollmann MW, van Zwam WH, van der
Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW,
Full protocol available at: helene.beloeil@chu-rennes.fr. Roos YB; MR CLEAN Investigators:The effect of anes-

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Raw data available at: helene.beloeil@chu-rennes.fr. thetic management during intra-arterial therapy for acute
stroke in MR CLEAN. Neurology 2016; 87:656–64
Correspondence 7. Bekelis K, Missios S, MacKenzie TA, Tjoumakaris
Address correspondence to Dr. Beloeil: Pole Anesthésie- S, Jabbour P: Anesthesia technique and outcomes of
Réanimation Medecine Interne Geriatrie, CHU Rennes, mechanical thrombectomy in patients with acute isch-
2 Avenue Henri Le Guillou, 35033 Rennes Cedex, France. emic stroke. Stroke 2017; 48:361–6
helene.beloeil@chu-rennes.fr. This article may be accessed 8. Campbell BCV, van Zwam WH, Goyal M, Menon
for personal use at no charge through the Journal Web site, BK, Dippel DWJ, Demchuk AM, Bracard S, White P,
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Rasmussen M, Sørensen KE, Simonsen CZ: Safety and
quality of endovascular therapy under general anesthesia Appendix
and conscious sedation are comparable: Results from the
GOLIATH trial. J Neurointerv Surg 2019; 11:1070–2 The following staff anesthesiologists provided and cared for
15. Zhang Y, Jia L, Fang F, Ma L, Cai B, Faramand A: study patients and collected data:
General anesthesia versus conscious sedation for intra- From Anesthesia and Intensive Care Department,
cranial mechanical thrombectomy: A systematic review University Rennes, CHU Rennes (Rennes, France):
and meta-analysis of randomized clinical trials. J Am Catherine Bléry, M.D., Maria Lahlou-Casulli, M.D., Patrick
Heart Assoc 2019; 8:e011754 L’hours, M.D., Audrey Sion, M.D., Simon Viquesnel, M.D.,
16. Pop R, Severac F, Happi Ngankou E, Harsan O, Martin Edouard Ngamiye, M.D., and Ange Ngendadumwe, M.D.
I, Mihoc D, Manisor M, Simu M, Chibbaro S, Wolff V, From Anesthesia Department, Rothschild Hospital
Gheoca R, Meyer A, Pottecher J, Audibert G, Derelle and Foundation (Paris, France): Laurie-Anne Thion, M.D.
AL,Tonnelet R, Liao L, Zhu F, Bracard S, Anxionnat R, From Anesthesia and Intensive Care Department, Brest
Richard S, Beaujeux R, Gory B: Local anesthesia ver- Teaching Hospital (Brest, France): Bénédicte Nancy, M.D.,
sus general anesthesia during endovascular therapy for Emilie Guillard, M.D., and Jean-Philippe Aubouin, M.D.
acute stroke: A propensity score analysis. J Neurointerv The following staff neuroradiologists provided and cared
Surg 2021; 13:207–11 for study patients and collected data:
17. Maurice A, Ferré JC, Ronzière T, Devys JM, Subileau From Radiology Department, Rennes Teaching
A, Laffon M, Laviolle B, Beloeil H; SFAR Research Hospital (Rennes, France): Jean-Christophe Ferret, M.D.,
Network: GASS trial study protocol: A multicentre, Ph.D., Jean-Yves Gauvrit, M.D., Ph.D. (who also partic-
single-blind, randomised clinical trial comparing gen- ipated in editing of the manuscript), and Helene Raoult,
eral anaesthesia and sedation during intra-arterial treat- M.D. From Radiology Department, Rothschild Hospital
ment for stroke. BMJ Open 2019; 9:e024249 and Foundation (Paris, France): Chistophe Paya, M.D.,
18. Schönenberger S, Hendén PL, Simonsen CZ, Uhlmann Anthony Le Bras, M.D., and Michel Piotin, M.D., Ph.D.
L, Klose C, Pfaff JAR, Yoo AJ, Sørensen LH, Ringleb From Radiology Department, Brest Teaching Hospital
PA, Wick W, Kieser M, Möhlenbruch MA, Rasmussen (Brest, France): Julien Ognard, M.D., Ph.D.
M, Rentzos A, Bösel J: Association of general anesthe- The following staff neurologists provided and cared for
sia vs procedural sedation with functional outcome study patients and collected data:
among patients with acute ischemic stroke undergoing From Neurology Department, Rennes Teaching Hospital
thrombectomy: A systematic review and meta-analysis. (Rennes, France): Veronica Lassale, M.D., and Stephane
JAMA 2019; 322:1283–93 Vannier, M.D. From Neurology Department, Rothschild
19. Fiehler J, Cognard C, Gallitelli M, Jansen O, Kobayashi Hospital and Foundation (Paris, France): Mickaël Mazighi,
A, Mattle HP, Muir KW, Mazighi M, Schaller K, M.D., Ph.D.
Schellinger PD: European Recommendations on The following members of the research team collected
Organisation of Interventional Care in Acute Stroke data and participated in editing the manuscript:
(EROICAS). Eur Stroke J 2016; 1:155–70 From Center of Clinical Investigation, Clinical
20. Rasmussen M, Espelund US, Juul N, Yoo AJ, Sørensen Pharmacology Department, University of Rennes, Rennes
LH, Sørensen KE, Johnsen SP, Andersen G, Simonsen Teaching Hospital, Inserm (Rennes, France): Claire
CZ: The influence of blood pressure management on Fougerou, Pharm.D., Aurelie Veslinger, C.R.A., Nadia
neurological outcome in endovascular therapy for acute Bouchard, C.R.A., and Catherine Hamon, Pharm.D.
ischaemic stroke. Br J Anaesth 2018; 120:1287–94 From Brest Teaching Hospital (Brest, France): Patricia
21. Rasmussen M, Schönenberger S, Hendèn PL, Valentin Dias, C.R.A. From the French Society of Anesthesiology
JB, Espelund US, Sørensen LH, Juul N, Uhlmann L, Research Network (Paris, France): Chafia Daoui, C.R.A.

576 Anesthesiology 2022; 136:567–76 Maurice et al.

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