Determinants of procedural sedation requirements during endovascular treatment for acute anterior circulation ischaemic stroke: a post-hoc analysis of the INDIVIDUATE trial

Why clinicians should know about it

• Picked for Anesthesiology and Pain Medicine (paper of the day, 2 September 2026): Male sex and occlusion type increased esketamine dose

Abstract

INTRODUCTION: Procedural sedation during EVT for acute ischaemic stroke is widely used, but factors associated with analgosedative drug requirements remain poorly characterised. We aimed to identify patient and procedural factors associated with analgosedative drug requirements during EVT and explore their association with clinical outcomes. PATIENTS AND METHODS: We performed a post hoc analysis of the randomised INDIVIDUATE trial, including patients with anterior circulation ischaemic stroke undergoing EVT under procedural sedation. Sedation exposure was quantified using mean propofol, remifentanil and esketamine dose rates derived from protocolised 5-min medication records. Multivariable linear regression analyses were used to identify factors associated with sedation requirements. Sensitivity analyses were performed using body weight-normalised dose rates in patients with available body weight data. Exploratory analyses assessed associations between sedation requirements and procedural and clinical outcomes. RESULTS: Of 250 patients enrolled in the INDIVIDUATE trial, 239 were included. In multivariable analyses, male sex was associated with higher propofol and esketamine dose rates; however, after body weight-normalisation, the association with propofol was no longer statistically significant. In weight-normalised sensitivity analyses including 198 patients (82.8%), male sex, ICA + M2 occlusion compared with M1 occlusion and pre-stroke disability remained associated with higher weight-normalised esketamine dose rates (β = 2.39 μg/kg/min, P = .021; β = 13.56 μg/kg/min, P < .001; and β = 2.82 μg/kg/min, P = .028, respectively). Additionally, the number of thrombectomy attempts was associated with higher remifentanil dose rates (β = 0.56 ng/kg/min, P = .010). Higher body weight-normalised esketamine dose rates were associated with less favourable NIHSS change at 24 h (β = 0.17, P = .022). Sedation requirements were not associated with 3-month functional outcome or mortality. CONCLUSION: Sedation requirements during EVT appeared to vary according to patient- and procedure-related factors, including sex, occlusion pattern, pre-stroke disability and procedural complexity. Sedation intensity was not associated with long-term clinical outcomes, supporting the use of adequate procedural sedation when clinically indicated. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov; NCT04578288.

Abstract as published, via PubMed.