Criteria for Thrombectomy / Endovascular Treatment of Stroke

Patients eligible for intravenous alteplase should receive intravenous alteplase even if endovascular treatments are being considered

Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria:

  1. prestroke mRS score 0–1,
  2. acute ischemic stroke receiving intravenous alteplase within 4.5 h of onset
  3. causative occlusion of the internal carotid artery or proximal MCA (M1),
  4. age >18 years, (note: there is no upper age limit),
  5. NIHSS score of C6,
  6. ASPECTS of C6
  7. treatment can be initiated (groin puncture) within 6 h of symptom onset

As with intravenous alteplase, reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better clinical outcomes

When treatment is initiated beyond 6 h from symptom onset, the effectiveness of endovascular therapy is uncertain for patients with acute ischemic stroke who havecausative occlusion of the internal carotid artery or proximal MCA (M1)

In carefully selected patients with anterior circulation occlusion who have contraindications to intravenous alteplase, endovascular therapy with stent retrievers completed within 6 h of stroke onset is reasonable

Although the benefits are uncertain, use of endovascular therapy with stent retrievers may be reasonable for carefully selected patients with acute ischemic stroke in whom treatment can be initiated (groin puncture) within 6 h of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries

Endovascular therapy with stent retrievers may be reasonable for some patients <18 years of age with acute ischemic stroke who have demonstrated large vessel occlusion in whom treatment can be initiated (groin puncture) within 6 h of symptom onset, but the benefits are not established in this age group

Observing patients after intravenous alteplase to assess for clinical response before pursuing endovascular therapy is not required to achieve beneficial outcomes and is not recommended

Endovascular therapy with stent retrievers is recommended over intra-arterial fibrinolysis as first-line therapy

It might be reasonable to favor conscious sedation over general anesthesia during endovascular therapy for acute ischemic stroke. However, the ultimate selection of anesthetic technique during endovascular therapy for acute ischemic stroke should be individualized based on patient risk factors, tolerance of the procedure, and other clinical characteristics

Reference:

Gross, H. and Grose, N. (2017). Emergency Neurological Life Support: Acute Ischemic Stroke. Neurocritical Care, 27(S1), pp.102-115.

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