Endovascular thrombectomy (EVT) is the standard of care for eligible patients with anterior circulation large vessel occlusion (LVO). The optimal anesthetic strategy during EVT for young adults with LVO remains unclear.

Using target trial emulation, we performed a pooled analysis of individual patient data from the DEVT, RESCUE BT, and MARVEL trials. We compared anesthetic strategies (general anesthesia [GA] vs . non-GA [conscious sedation/local anesthesia]) during EVT in patients aged 18–50 years. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] 0–2). Secondary outcomes included ordinal mRS shift, excellent outcome (mRS 0–1), favorable outcome (mRS 0−3), successful reperfusion (expanded Thrombolysis in Cerebral Infarction [eTICI] grade ≥2b), early neurological improvement (ENI), pneumonia, mortality, and symptomatic intracranial hemorrhage (sICH). Average treatment effects were estimated via inverse probability of treatment weighting (IPTW) and G-computation, with risk differences (RDs) and (common) odds ratios (ORs) reported.

Among 284 included patients in the target trial, 94 received GA and 190 received non-GA. Non-GA was associated with higher rates of 90-day functional independence (mRS 0–2) compared to GA (RD 0.12, 95%CI: 0.02 to 0.25). GA was associated with increased pneumonia incidence (RD −0.21, 95%CI: −0.35 to −0.11). Additionally, reperfusion success, mortality, and sICH rates did not differ significantly between groups.

In this emulated trial involving young stroke patients undergoing EVT, non-GA was associated with a higher likelihood of functional independence compared to GA with similar reperfusion success and sICH. These findings may inform anesthetic selection for young adults with anterior circulation LVO pending a dedicated randomized trial.

ChiCTR.org.cn Identifier: ChiCTR-IOR-17013568; ChiCTR-IOR-17014167; ChiCTR2100051729