Mechanical thrombectomy

Current treatment recommendations regarding mechanical thrombectomy

(Evidence grade within parentheses)

• Mechanical thrombectomy, in addition to intravenous thrombolysis within 4.5 hours when eligible, is recommended to treat acute stroke patients with large artery occlusions in the anterior circulation up to 6 hours after symptom onset (Grade A)
• Mechanical thrombectomy should not prevent the initiation of intravenous thrombolysis where this is indicated, and intravenous thrombolysis should not delay mechanical thrombectomy (Grade A)
• Mechanical thrombectomy should be performed as soon as possible after its indication (Grade A)
• For mechanical thrombectomy, stent retrievers approved by local health authorities should be considered (Grade A)
• Other thrombectomy or aspiration devices approved by local health authorities may be used upon the neurointerventionists discretion if rapid, complete and safe revascularisation of the target vessel can be achieved (Grade C)
• If intravenous thrombolysis is contraindicated (e.g. Warfarin-treated with therapeutic INR) mechanical thrombectomy is recommended as first-line treatment in large vessel occlusions (Grade A)
• Patients with acute basilar artery occlusion should be evaluated in centres with multimodal imaging and treated with mechanical thrombectomy in addition to intravenous thrombolysis when indicated (Grade B) alternatively they may be treated within a randomized controlled trial for thrombectomy approved by the local ethical committee
• The decision to undertake mechanical thrombectomy should be made jointly by a multidisciplinary team comprising at least a stroke physician and a neurointerventionalist and performed in experienced centres providing comprehensive stroke care and expertise in neuroanesthesiology (Grade C)
• Mechanical thrombectomy should be performed by a trained and experienced neurointerventionalist who meets national and/or international requirements (Grade B)
• The choice of anesthesia depends on the individual situation; independently of the method chosen, all efforts should be made to avoid thrombectomy delays (Grade C)
• Intracranial vessel occlusion must be diagnosed with non-invasive imaging whenever possible before considering treatment with mechanical thrombectomy (Grade A)
• If vessel imaging is not available at baseline, a NIHSS score of ≥ 9 within three, and≥ 7 points within six hours may indicate the presence of large vessel occlusion (Grade B)
• Patients with radiological signs of large infarcts (for ex. using the ASPECTS score) may be unsuitable for thrombectomy (Grade B)
• Imaging techniques for determining infarct and penumbra sizes can be used for patient selection and correlate with functional outcome after mechanical thrombectomy (Grade B)
• High age alone is not a reason to withhold mechanical thrombectomy as an adjunctive treatment (Grade A)

References

• 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke, Stroke. 2018 Mar;49(3):e46-e110 doi: 10.1161/STR.0000000000000158