Anesthesia and the Periprocedural Management of Large Vessel Occlusion Stroke Treated with Mechanical Thrombectomy: A Narrative Review.

Abstract

Mechanical thrombectomy is the standard of care for acute ischemic stroke due to large vessel occlusion and has markedly improved functional outcomes. While procedural sedation was historically favored instead of general anesthesia due to safety concerns, current evidence does not support superior functional outcomes with procedural sedation compared with protocol-driven general anesthesia. General anesthesia is associated with higher reperfusion rates; however, strict hemodynamic control-particularly avoidance of hypotension-and ventilatory management are critical to preserving cerebral perfusion and improving outcomes. Ongoing trials are expected to clarify optimal anesthetic strategies in both anterior and posterior circulation strokes. In the meantime, the choice between general anesthesia and procedural sedation should consider patient-specific characteristics, procedural complexity, and institutional expertise. Future research should focus on better defining patient selection or stroke subtypes most likely to benefit from general anesthesia or procedural sedation, hemodynamic management, and neuroprotective strategies to maximize reperfusion, minimize complications, and improve recovery.