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General anesthesia during endovascular therapy for acute ischemic stroke didn't make patients worse off than if they had gotten conscious sedation, a single-center randomized trial showed -- and outcomes were arguably better.

MRIs scans before thrombectomy and 48 to 72 hours afterward showed that infarcts had grown a median of , which was not a significant difference for this primary endpoint, a group led by Claus Simonsen, MD, PhD, of Aarhus University Hospital in Denmark, reported online in JAMA Neurology.

However, final infarct volumes did favor general anesthesia (22.3 versus 38.0 mL, P=0.04) in the open-label GOLIATH trial, which randomized 128 patients whose strokes were caused by large vessel occlusions in the anterior circulation within 6 hours of onset to general anesthesia or conscious sedation.

Operators were more likely to achieve successful reperfusion (mTICI 2b to 3) with general anesthesia (76.9% versus 60.3% conscious sedation, P=0.04). Furthermore, this group was more likely to have a favorable functional outcome at 90 days (modified Rankin Scale score median 2 for both, OR 1.91, 95% CI 1.03-3.56).

"Contrary to numerous nonrandomized studies that have reported better outcomes with conscious sedation, the GOLIATH trial shows signals in favor of general anesthesia for multiple endpoints," Simonsen's group suggested.

"These data seem to support the idea that endovascular therapy might be performed with greater technical success when patients are under general anesthesia and not moving, but no such benefits in terms of reperfusion and functional outcome were seen in the general anesthesia arm of the AnStroke trial."

A major caveat of the study was its single-center design. "Another limitation of the GOLIATH trial, and the other trials, is the relatively small sample size, which may potentially cause important differences between the treatment arms to be missed. Indeed, given the observed numerical difference in infarcts growth in favor of general anesthesia, our study may have been underpowered for the primary endpoint," Simonsen and colleagues acknowledged.

Limitations aside, what they could conclude was that "[t]aken together, the recent randomized trials of anesthesia for endovascular therapy demonstrate that general anesthesia does not necessarily lead to worse outcomes after endovascular therapy."

Participants in the present GOLIATH analysis had a mean age of 71.4 years and were 48.4% women. The median National Institutes of Health Stroke Scale score was 18. Notably, 6.3% of the conscious sedation group crossed over to general anesthesia.

The two arms had balanced baseline characteristics, except that recipients of conscious sedation got groin puncture sooner after arriving at the neurointerventional suite (15 versus 24 min with general anesthesia, P<0.001).

"This time delay for induction and intubation is acceptable in the context of the much longer overall time from stroke onset to treatment and from stroke onset to reperfusion, which was not significantly different between the competing arms," the authors wrote.

Ninety-day mortality risks were similar between arms (7.7% versus 12.7%, P=0.35).

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