Acute ischemic stroke is a neurological emergency with a high likelihood of morbidity, mortality, and long-term disability. Modern
stroke care involves multidisciplinary management by neurologists, radiologists, neurosurgeons, and anesthesiologists. Current American Heart Association/American
Stroke Association (AHA/ASA) guidelines recommend
thrombolytic therapy with intravenous (IV)
alteplase within the first 3-4.5 hours of initial
stroke symptoms and endovascular mechanical
thrombectomy within the first 16-24 hours depending on specific inclusion criteria. The
anesthesia and
critical care provider may become involved for
airway management due to worsening neurologic status or to enable computerized tomography (CT) or magnetic resonance imaging (MRI) scanning, to facilitate mechanical
thrombectomy, or to manage
critical care of
stroke patients. Existing data are unclear whether the mechanical
thrombectomy procedure is best performed under
general anesthesia or sedation. Retrospective cohort trials favor sedation over
general anesthesia, but recent randomized controlled trials (RCT) neither suggest superiority nor inferiority of sedation over
general anesthesia. Regardless of
anesthesia type, a critical
element of intraprocedural
stroke care is tight blood pressure management. At different phases of
stroke care, different blood pressure targets are recommended. This narrative review will focus on the
anesthesia and
critical care providers' roles in the management of both perioperative
stroke and
acute ischemic stroke with a focus on
anesthetic management for mechanical
thrombectomy.