Anesthesia for acute ischemic stroke after the 2026 AHA/ASA guideline: a peri-thrombectomy practice framework

Abstract The 2026 American Heart Association/American Stroke Association guideline for acute ischemic stroke expands eligibility for endovascular thrombectomy, broadens the role of tenecteplase, recommends against routine intensive post-reperfusion systolic blood pressure lowering, introduces an explicit recommendation against intensive glucose control to 80–130 mg/dL, and includes dedicated pediatric recommendations. Although the guideline is not written primarily for anesthesiologists, its implementation directly affects peri-thrombectomy care. This narrative review translates the 2026 guideline into an implementation-oriented practice framework for anesthesia teams. Recommendations are explicitly labeled as either guideline-derived or as pragmatic anesthesia implementation suggestions informed by supporting literature. Topics covered are rapid preprocedural assessment, choice between general anesthesia and procedural sedation (including triggers for conversion from sedation to general anesthesia), hemodynamic management before and after recanalization, ventilation and metabolic targets, anesthetic drug selection, neuromonitoring, post-thrombectomy handover, and pediatric considerations. Practice-model variation is acknowledged, and the framework distinguishes physiologic and escalation principles applicable across staffing models from elements specific to continuous anesthesia-led care. Areas of substantive uncertainty include posterior-circulation anesthetic technique, pediatric peri-procedural management, and the role of intraprocedural neuromonitoring.