Anterior circulation acute ischemic stroke: Endovascular mechanical thrombectomy indications and perioperative anaesthetic management

Mechanical thrombectomy (MT), associated with intravenous thrombolysis if possible, is recommended since 2015 in proximal anterior circulation acute ischemic stroke in selected patients. The procedure is beneficial whatever the age of the patient, but requires urgent medical attention in specialised centres. Strict patient selection with scanners evaluating perfusion mismatch can prolong delay up to 24 hours post stroke symptoms. Peri-interventional procedure, notably anaesthesia, is important. The aim is to secure MT for the patient and the operator related to airway management, comfort, analgesia and movements control. Also, protection of the ischemic penumbra needs maintenance of blood pressure, oxygenation and other determinants of cerebral metabolism. General anaesthesia (GA) or procedural sedation (conscious sedation (CS)), if not local anaesthesia, could be used. For many years, it was assumed that GA altered outcome. Nevertheless, study results were impacted by consequent selection bias. Recent data found at least equipoise between GA and CS. Some randomised trials and one meta-analysis on individual patient data found better outcomes associated with GA. However, multicentric trials are urgently needed. One thing is for certain: coordination and organisation of emergency medicine, vascular neurology, interventional neuroradiology and anaesthesia-perioperative medicine teams are truly essential.