Early vs Delayed Extubation After Thrombectomy for Acute Ischemic Stroke: The EDESTROKE Randomized Clinical Trial.

Abstract

The optimal timing of extubation after endovascular thrombectomy performed under general anesthesia for patients with acute ischemic stroke remains uncertain. To evaluate whether early extubation (<6 hours) compared with delayed extubation (6-12 hours) after successful thrombectomy under general anesthesia improves 90-day functional outcomes. This randomized clinical trial was conducted at a single tertiary academic referral center from April 2023 to June 2025 with 90 days of follow-up. Participants were adults (age ≥18 years) with acute ischemic stroke due to anterior circulation large-vessel occlusion who underwent successful endovascular thrombectomy under general anesthesia. Participants were randomly assigned (1:1) to receive early (<6 hours) or delayed (6-12 hours) extubation following thrombectomy. The primary outcome was functional independence at 90 days (as indicated by a modified Rankin Scale [mRS] score of 0-2). Secondary outcomes included the ordinal distribution of mRS scores, length of hospital stay, respiratory and procedure-related complications, and 90-day mortality. Of 312 patients assessed, 174 were randomized, 87 to receive early extubation and 87 to delayed extubation. Ninety-eight patients (56.3%) were women and 76 (43.7%) were men; the median (IQR) age was 76 (69-86) years. Functional independence at 90 days occurred in 41 of 86 patients (47.7%) in the early group and 39 of 85 (45.9%) in the delayed group (risk ratio [RR], 1.04; 95% CI, 0.76 to 1.43). The ordinal analysis of mRS scores showed no significant difference between groups (generalized odds ratio, 0.93; 95% CI, 0.66 to 1.31). Median (IQR) length of hospital stay was 6 (3-9.5) days in the early group and 6 (4-10) days in the delayed group (median difference, 0.0 days; 95% CI, -1.81 to 1.81). The incidence of pneumonia was 19 patients (21.8%) in the early group and 26 patients (29.9%) in the delayed group (RR, 0.73; 95% CI, 0.44 to 1.22), and reintubation occurred in 4 patients (4.6%) vs 2 patients (2.3%), respectively (RR, 2.00; 95% CI, 0.37 to 10.9). Mortality at 90 days was 20 of 86 patients (23.3%) in the early group vs 19 of 85 patients (22.4%) in the delayed group (RR, 1.04; 95% CI, 0.60 to 1.81). Among patients with acute ischemic stroke undergoing successful thrombectomy under general anesthesia, early extubation (<6 hours) did not improve functional independence compared with delayed extubation (6-12 hours). ClinicalTrials.gov Identifier: NCT05847309.