Abstract Background and aims The optimal anesthetic strategy during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) remains uncertain. While general anesthesia (GA) offers immobility, conscious sedation (CS) may expedite the procedure and reduce hemodynamic instability. We aimed to compare functional, technical, and safety outcomes of GA versus CS during EVT using an updated meta-analysis of randomized controlled trials (RCTs). Methods We conducted a systematic review and meta-analysis of RCTs comparing GA with CS in adults undergoing EVT for AIS (PROSPERO CRD420251168437). We searched PubMed, Embase, Web of Science, Scopus, and Cochrane Central from inception to 15 October 2025. The clinical outcome was functional independence (modified Rankin Scale mRS 0-2) at 90 days. The technical outcome was successful reperfusion (modified Thrombolysis in Cerebral Infarction mTICI 2b-3). The safety outcome was 90-day mortality. Random-effects models with the Hartung–Knapp–Sidik–Jonkman method were used. Results Nine RCTs comprising 1,460 patients (GA: n=726; CS: n=734) were included. GA was associated with higher rates of successful reperfusion compared with CS (RR 1.11; 95% CI 1.03-1.19; p=0.01). However, there was no significant difference in functional independence at 90 days (RR 1.13; 95% CI 0.93-1.39; p=0.22). Furthermore, 90-day mortality did not differ between groups (RR 0.89; 95% CI 0.60-1.31; p=0.55). Conclusions GA was associated with higher rates of successful reperfusion compared to CS during EVT for AIS. However, this technical advantage did not translate into significant differences in functional independence or mortality at 90 days. Anesthetic choice should be individualized based on patient characteristics and local expertise. Conflict of interest Shih-Syuan Wang: nothing to disclose. Aashish Baniya: nothing to disclose. Sanghyo Lee: nothing to disclose. Oluwaseun Williams: nothing to disclose. Hyunah Choi: nothing to disclose. Chun-Yu Peng: nothing to disclose. Shao-Wei Lo: nothing to disclose. Tsu-Hsien Wang: nothing to disclose. Wei-Jun Lee: nothing to disclose. Cho-Han Chiang: nothing to disclose. Figure 1 - belongs to Results
Wang et al. (2026) studied this question.