MR CLEAN: Awake Is Better

The research protocols in the MR CLEAN trial of clot-retrieval vs. tPA in treatment of a subset of stroke patients with serious ischemic strokes left one treatment decision up to each participating center. Physicians were to decide whether patients should be immobilized with general anesthesia or given local anesthesia.

Presenting another look-back at MR CLEAN trial data at the American Heart Association/American Stroke Association International Stroke Conference in Nashville, Tenn. on Feb. 13, Olvert Berkhemer, MD and colleagues said their center’s strong preference is for local anesthesia.

In his post-hoc analysis of the ground-breaking trial, Berkhemer said there are pluses and minuses to each type of anesthesia. General anesthesia is easier on the patient emotionally, keeps the patient still, and thus makes it easier and less stressful for physicians to find the clot with imaging, thread the clot retriever into the brain, grab it, and pull it out. If a patient lies still the physicians have better access to blood vessels and get a better scanned image of the area that is being impacted by the embolus.

“When we pull it out, sometimes it hurts, and the patient moves and you can perforate a vessel,” Berkhemer said, “The challenge is always to keep the patient still and sometimes you can’t do it without general anesthesia.” But he added, “General anesthesia has its own negative effects.”

It takes longer to initiate, and it lowers blood pressure at a critical time when normal blood pressure is needed to get blood into the brain and reperfuse tissue before it dies.

“Local is faster and time is brain,” he said. In the MR CLEAN trial at his hospital, the Academic Medical Center, Amsterdam, NL, of 217 patients who underwent the intra-arterial treatment, patients who had local anesthesia had a better outcome 90 days later: 38 % had fully recovered or had slight disability compared with 23 % of the general anesthesia group who had a similarly good outcome.

The rates of brain bleeding or death were similar.

Six of the patients who started out getting local anesthesia could not tolerate the procedure and had to be put under general anesthesia, Berkhemer said.