Optimising Anaesthesia for Endovascular Thrombectomy in Acute Ischaemic Stroke: A Narrative Review on the use of General Anaesthesia versus Conscious Sedation

Acute Ischaemic Stroke (AIS) due to Large Vessel Occlusion (LVO) remains a leading cause of mortality and long-term disability worldwide, with Endovascular Thrombectomy (EVT) established as the gold standard of treatment when performed rapidly. Anaesthetic management is pivotal in influencing procedural success, safety, and neurological outcomes, yet the choice between General Anaesthesia (GA) and Conscious Sedation (CS) remains controversial. GA offers advantages of airway protection, patient immobility, and optimal procedural conditions; however, it is often associated with haemodynamic instability, potential delays in treatment initiation, and risks of prolonged recovery. In contrast, CS allows for continuous neurological assessment and may reduce treatment times, but carries the risk of patient agitation, airway compromise, and the need for conversion to GA, which can adversely affect outcomes. Recent randomised controlled trials, meta-analyses, and large-scale observational studies have attempted to clarify this debate, with many reporting broadly comparable rates of functional independence, recanalisation success, and mortality between GA and CS. However, subtle differences persist regarding haemodynamic stability and complication profiles. Evidence also suggests that protocol-driven approaches, hybrid strategies, and institutional preparedness significantly influence outcomes, highlighting that anaesthetic technique cannot be considered in isolation. The evolving literature supports a balanced, patient-centred approach in which anaesthetic choice is guided by clinical condition, airway safety, operator preference, and institutional expertise rather than a rigid protocol. Ultimately, tailored anaesthetic management remains critical to maximising neurological recovery, minimising peri-procedural risks, and optimising workflow efficiency in patients undergoing EVT for AIS. This review introduces a novel, patient-centred framework for anaesthetic management in EVT, focussing on individual clinical and institutional factors to optimise outcomes and workflow efficiency.