Early vs Delayed Extubation After Thrombectomy for Acute Ischemic Stroke

Importance: The optimal timing of extubation after endovascular thrombectomy performed under general anesthesia for patients with acute ischemic stroke remains uncertain. Objective: To evaluate whether early extubation (<6 hours) compared with delayed extubation (6-12 hours) after successful thrombectomy under general anesthesia improves 90-day functional outcomes. Design, Setting, and Participants: This randomized clinical trial was conducted at a single tertiary academic referral center from April 2023 to June 2025 with 90 days of follow-up. Participants were adults (age ≥18 years) with acute ischemic stroke due to anterior circulation large-vessel occlusion who underwent successful endovascular thrombectomy under general anesthesia. Interventions: Participants were randomly assigned (1:1) to receive early (<6 hours) or delayed (6-12 hours) extubation following thrombectomy. Main Outcomes and Measures: The primary outcome was functional independence at 90 days (as indicated by a modified Rankin Scale [mRS] score of 0-2). Secondary outcomes included the ordinal distribution of mRS scores, length of hospital stay, respiratory and procedure-related complications, and 90-day mortality. Results: Of 312 patients assessed, 174 were randomized, 87 to receive early extubation and 87 to delayed extubation. Ninety-eight patients (56.3%) were women and 76 (43.7%) were men; the median (IQR) age was 76 (69-86) years. Functional independence at 90 days occurred in 41 of 86 patients (47.7%) in the early group and 39 of 85 (45.9%) in the delayed group (risk ratio [RR], 1.04; 95% CI, 0.76 to 1.43). The ordinal analysis of mRS scores showed no significant difference between groups (generalized odds ratio, 0.93; 95% CI, 0.66 to 1.31). Median (IQR) length of hospital stay was 6 (3-9.5) days in the early group and 6 (4-10) days in the delayed group (median difference, 0.0 days; 95% CI, -1.81 to 1.81). The incidence of pneumonia was 19 patients (21.8%) in the early group and 26 patients (29.9%) in the delayed group (RR, 0.73; 95% CI, 0.44 to 1.22), and reintubation occurred in 4 patients (4.6%) vs 2 patients (2.3%), respectively (RR, 2.00; 95% CI, 0.37 to 10.9). Mortality at 90 days was 20 of 86 patients (23.3%) in the early group vs 19 of 85 patients (22.4%) in the delayed group (RR, 1.04; 95% CI, 0.60 to 1.81). Conclusions and Relevance: Among patients with acute ischemic stroke undergoing successful thrombectomy under general anesthesia, early extubation (<6 hours) did not improve functional independence compared with delayed extubation (6-12 hours). Trial Registration: ClinicalTrials.gov Identifier: NCT05847309.