{
  "abstract": "Backgrounds Multiple randomized controlled trials have demonstrated conflicting effects of anesthetic modality, general anesthesia (GA) or conscious sedation (CS), on the outcomes of mechanical thrombectomy (MT). We investigated the impact of center-level anesthesia practice pattern on outcomes.Methods In the Neurovascular Quality Initiative database, patients presenting to centers with > 50 cases per submitted data year within 2020-2025 and with ICA, M1, and M2 occlusions were identified. Centers were characterized by the proportion of cases performed with GA (0-30%: GA-dominant; 30-70%: mixed; 70-100%: CS-dominant). Practice deviant cases were identified as those patients treated with the less common modality at GA- and CS-dominant centers. Multivariable generalized linear mixed models with random intercepts for center estimated independent effects of anesthetic type and center practice pattern. Mediation analysis compared center-type parameters in models with and without the inclusion of individual anesthetic choice.Findings In total, 8,410 MT cases were reported from 2 CS-dominant centers (N=1,238 cases), 18 GA-dominant centers (N=5,906 cases), and 4 mixed practice centers (N=1,266 cases). CS dominant centers achieved the shortest median door-to-reperfusion time (85 minutes, IQR 55-118), compared to mixed-practice (95 minutes, IQR 70-127) and GA-dominant centers (98 minutes, IQR 66-135, p<0.001). Technical outcomes followed a consistent gradient: FPE was highest at CS-dominant centers (42.4%), intermediate at GA-dominant centers (37.3%), and lowest at mixed-practice centers (30.7%, p<0.001), with modified FPE (52.3% vs. 49.6% vs. 41.5%, p<0.001) and failed reperfusion (4.6% vs. 4.9% vs. 6.9%, p=0.009) following the same pattern. On multivariable analysis, GA was associated with lower FPE (adjusted OR 0.70, [95%CI 0.58-0.85], p<0.001), but center practice pattern was not.In-hospital mortality was lowest at CS-dominant centers (8.5%), with GA-dominant (11.9%) and mixed-practice centers (12.1%) performing similarly. CS-dominant centers had the shortest median hospital stay (4 days, IQR 2-8) and lowest ICU utilization (21.9%), compared to mixed-practice (6 days, 87.4% ICU) and GA-dominant centers (8 days, 98.0% ICU). GA was associated with increased mortality in multivariable analysis (aOR 1.42, [95%CI 1.04-1.94], p=0.028) adjusting for age, NIHSS, thrombolysis, and time from last know well. In mediation analysis, anesthetic selection explained 63% of the mortality effect associated with GA-dominant centers, but only 31% of the mixed-center effect.Conclusions CS-dominant centers reported faster reperfusion, superior technical success, lower hospital length of stay, and lower in-hospital mortality. Individual GA use was associated with reduced FPE and increased mortality, but anesthetic selection alone explained only 31% of the excess mortality at mixed-practice centers, compared to 63% at GA-dominant centers, suggesting practice inconsistency may be a risk factor for worsened outcomes. Further research is required to evaluate the role of institutional experience on the effects of anesthetic choice and may inform the design of future randomized trials.Disclosures J. Feler: None. C. Doberstein: None. R. Torabi: None. K. Moldvovan: None. E. Shaaya: None.Abstract E-119 Table 1CS-Dominant (N=1,238)GA-Dominant (N=5,906)Mixed Practice (N=1,266)p valueFirst-pass effect, n (%)712 (57.6%)3651 (62.7%)874 (69.3%)< 0.001Modified first-pass effect, n (%)645 (52.3%)2,853 (49.6%)523 (41.5%)< 0.001Successful recanalization (TICI ≥2b), n (%)1,137 (91.8%)5,297 (89.7%)1,085 (85.7%)< 0.001Door-to-reperfusion, median min (IQR)85 (55-118)98 (66-135)95 (70-127)< 0.001Hospital LOS, median days (IQR)4 (2-8)8 (4-13)6 (4-11)< 0.001Any ICU admission, n (%)271 (21.9%)5,789 (98.0%)1,106 (87.4%)< 0.001ICU LOS, median days (IQR)4 (2-6)3 (2-5)1,106 2 (1-4)< 0.00124-hour NIHSS, median (IQR)7 (2-16)11 (4-18)8 (3-16)< 0.001In-hospital mortality, n (%)105 (8.5%)699 (11.9%)152 (12.1%)0.002",
  "authors": [
    {
      "affiliations": [
        "Department of Neurosurgery, Brown University, Providence, RI"
      ],
      "name": "J Feler"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Brown University, Providence, RI"
      ],
      "name": "C Doberstein"
    },
    {
      "affiliations": [
        "Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI"
      ],
      "name": "AA Teshome"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Brown University, Providence, RI"
      ],
      "name": "R Torabi"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Brown University, Providence, RI"
      ],
      "name": "K Moldvovan"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Brown University, Providence, RI"
      ],
      "name": "E Shaaya"
    },
    {
      "affiliations": [
        "Rhode Island Hospital, Providence, RI"
      ],
      "name": "M Jayaraman"
    },
    {
      "affiliations": [
        "Diagnostic Imaging, The Warren Alpert School of Medicine at Brown University, Providence, RI"
      ],
      "name": "DN Wolman"
    }
  ],
  "title": "E-119 Center-level utilization of general anesthesia for mechanical thrombectomy is associated with mortality, a neurovascular quality initiative registry study",
  "uid": "825741d2-2123-5b8b-a899-523e4def32cd"
}