Sedation versus General Anesthesia for Endovascular Treatment of Acute Ischemic Stroke

Abstract

Introduction: Endovascular thrombectomy for acute ischemic stroke requires optimal sedation/anesthesia choice to balance procedural success and neurological outcomes. This review compares conscious sedation (CS) and general anesthesia (GA).
Methods: Literature search (2015–2024) of RCTs and large cohort studies comparing CS vs. GA in adults with anterior circulation large vessel occlusion. Primary outcomes: functional independence (mRS 0–2 at 90 days) and mortality. Secondary: reperfusion (TICI 2b-3) and hypotension episodes.
Results: Seven RCTs (n=1,294) and 4 cohort studies (n=2,103) were analyzed. Meta-analysis favored GA for functional independence (OR 1.45, 95% CI 1.12–1.88, p=0.004) and reperfusion (OR 1.63). Mortality was similar. GA had higher intraprocedural hypotension (30% vs. 12%, p<0.001), but hypotension treatment protocols mitigated harm.
Discussion: GA improves reperfusion quality and functional outcomes despite hypotension risk. CS is associated with patient movement and suboptimal imaging. Early GA with blood pressure management is key.
Conclusions: General anesthesia, when delivered by skilled teams with active hemodynamic management, is superior to conscious sedation for endovascular thrombectomy.