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There has been a long-standing debate regarding the optimal approach to the anesthetic management of patients undergoing mechanical thrombectomy. While the vast majority of intracranial neurointerventional procedures are performed under general anesthesia (GA), thrombectomy has been treated differently. Thrombectomy cases are fundamentally different from traditional cases in that they occur at all hours of the day (and night) and always represent a time-critical emergency. At many institutions the anesthetic management of these patients is left to the available general on-call anesthesia staff, or sometimes they are performed without an anesthesiologist at all. It is the rare exception that a dedicated, experienced, on-call cerebrovascular anesthesia team is available. As thrombectomy has become established as the standard of care for emergent large vessel occlusion (ELVO), it is time that neurointerventional surgery evolves in the same direction as have other subspecialties such as cardiothoracic surgery, which typically have a dedicated, specialized, anesthesia team.

Until recently, most studies had suggested that GA led to higher mortality rates and worse neurological outcomes for thrombectomy patients. In general, these studies were methodologically weak, inherently biased, and either post hoc analyses of prospective studies or altogether retrospective.

To date, three randomized controlled trials have analyzed this very …