Local versus general anaesthesia for carotid endarterectomy

Rerkasem K, Rothwell PM

Published Online:

July 8, 2009

About 20% of strokes result from narrowing of the carotid artery (the main artery supplying blood to the brain). Blood clots can form at the point of narrowing. If a blood clot breaks off into the bloodstream, it can be carried into the brain, block the blood supply there and cause a stroke. A surgical operation (carotid endarterectomy) to remove this narrowing and the blood clot can lower the risk of stroke. Even with very careful surgery, in about one in 20 patients the operation itself causes a stroke. Local rather than general anaesthesia might lower the risk of a stroke happening during surgery. This review included 10 randomised trials, involving 4335 operations, of local anaesthetic versus general anaesthetic. There was no significant difference between the anaesthetic techniques in the risk of stroke or death during, or soon after, surgery. This review therefore shows that patients and surgeons can choose either anaesthetic technique, depending on the clinical situation and their own preferences.

Abstract (click to read)

Background:

Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic. This is an update of a Cochrane Review first published in 1996, and previously updated in 2008.

Objectives:

To assess the risks of endarterectomy under local compared with general anaesthetic.

Search strategy:

We searched the Cochrane Stroke Group Trials Register (last searched September 2008), MEDLINE (1966 to November 2008), EMBASE (1980 to November 2008) and Index to Scientific and Technical Proceedings (ISTP) (1980 to November 2008). We also handsearched six relevant journals to September 2008, and searched the reference lists of articles identified.

Selection criteria:

Randomised trials comparing carotid endarterectomy under local versus general anaesthetic.

Data collection and analysis:

Two review authors assessed trial quality and extracted the data independently.

Main results:

Ten randomised trials involving 4335 operations were included, of which 3526 were from the single largest trial (GALA). Meta-analysis of the randomised studies showed that there was no evidence of a reduction in the odds of operative stroke or death (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.63 to 1.16). There was a trend towards lower operative mortality with local anaesthetic (OR 0.62, 95% CI 0.36 to 1.07), but neither the GALA trial nor the pooled analysis were powered to detect an effect on mortality reliably.

Authors' conclusions:

The risk of stroke and death did not differ significantly between the two types of anaesthetic technique during carotid endarterectomy. This review provides evidence to support a policy that patients and surgeons can choose either anaesthetic technique, depending on the clinical situation and their own preferences.

This record should be cited as:

Rerkasem K, Rothwell PM. Local versus general anaesthesia for carotid endarterectomy. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD000126. DOI: 10.1002/14651858.CD000126.pub3

Assessed as up to date:

February 16, 2009

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Primary Review Group:

Stroke Group

Health topics:

Heart & circulation > Stroke > Ischemic stroke/TIA: prevention

Neurology > Stroke > Ischemic stroke/TIA: prevention

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Local versus general anaesthesia for carotid endarterectomy

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