Abstract Background and aims The optimal anesthetic strategy during endovascular thrombectomy for acute ischemic stroke remains controversial. Observational studies have suggested worse outcomes with general anesthesia, whereas randomized trials have shown inconsistent results. Early neurological improvement represents an important short-term outcome reflecting the immediate impact of anesthetic management during thrombectomy. Methods Systematic review and meta-analysis were conducted in accordance with a prospectively registered protocol (PROSPERO ID: CRD420251175962). Comparative studies evaluating conscious sedation versus general anesthesia in patients with acute ischemic stroke undergoing endovascular thrombectomy were included. Full-text screening was completed. Early neurological improvement was assessed using changes in the National Institutes of Health Stroke Scale (NIHSS). Meta-analysis was performed using RevMan when outcomes were sufficiently comparable. Results Forty-six studies met the inclusion criteria, including randomized controlled trials and observational cohorts. In the AnStroke trial, NIHSS scores at 24 hours were similar between general anesthesia and conscious sedation (median 8 IQR 3–15 vs 9 IQR 2–15; P=0.60), with no difference in NIHSS shift at 24 hours (P=0.27). Favorable functional outcome at 3 months (modified Rankin Scale ≤2) occurred in 42.2% under general anesthesia and 40.0% under conscious sedation (P=1.00). Similarly, the GOLIATH and SIESTA trials reported no statistically significant differences in early neurological improvement between anesthetic strategies. Successful reperfusion rates were comparable across strategies, while general anesthesia was associated with higher rates of peri-procedural hypotension and pneumonia in some studies. Conclusions Current evidence does not demonstrate a clear superiority of conscious sedation or general anesthesia for early neurological improvement following endovascular thrombectomy. Conflict of interest
Shahabi et al. (Fri,) studied this question.
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