Background: Endovascular thrombectomy (EVT) is the first-line treatment for patients with acute ischemic stroke (AIS). However, the optimal anesthetic modality during EVT is unclear. Therefore, this systematic review and meta-analysis is aimed to summarize the current literatures from RCTs to provide new clinical evidence of choosing anesthetic modality for AIS patients when receiving EVT. Methods: Literature search was conducted in following databases, EMBASE, MEDLINE, Web of Science, and the Cochrane Library, for relevant randomized controlled trials (RCTs) comparing general anesthesia (GA) and conscious sedation (CS) for AIS patients during EVT. We used the Cochrane Collaboration criteria for assessment of risk bias of included studies. The heterogeneity of outcomes was assessed by I2statistic. Results: 5 RCTs with 498 patients were included. GA was conducted in 251 patients and CS in 247 patients. EVT under GA in AIS patients had higher rates of successful recanalization (RR: 1.13, 95% CI: 1.04–1.23; P = 0.004; I2 = 40.6%) and functional independence at 3 months (RR: 1.28, 95% CI: 1.05–1.55; P = 0.013; I2 = 18.2%) than CS. However, GA was associated with higher risk of mean arterial pressure (MAP) drop (RR: 1.71, 95% CI: 1.19–2.47; P < 0.01; I2 = 80%) and pneumonia (RR: 2.32, 95% CI: 1.23–4.37; P = 0.009; I2 = 33.5%). There was no difference between GA and CS groups in mortality at 3 months, interventional complications, intracerebral hemorrhage and cerebral infarction after 30 days. Conclusions: GA was superior over CS in successful recanalization and functional independence at 3 months when performing EVT in AIS patients. However, GA was associated with higher risk of MAP drop and pneumonia. Therefore, results of ongoing RCTs will provide new clinical evidence of anesthetic modality selection during EVT in the future. © 2021