Purpose of reviewThis review discusses the general anesthetic approach of endovascular stroke therapy and highlights recent advances and considerations for optimal intraoperative management of acute ischemic stroke. Recent findingsRecent randomized controlled trials have shown no differences in clinical outcomes between monitored anesthesia care with sedation compared with general anesthesia for endovascular stroke therapy. The COVID-19 pandemic has complicated decision-making in the neurointerventional setting. Advances in imaging techniques have extended the window of treatment for endovascular therapy.