ESO/ESMINT Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke
European Stroke Organisation (ESO)along with European Society for Minimally Invasive Neurological Therapy (ESMINT) has released guidelines on Mechanical thrombectomy in Acute Ischemic Stroke. The guidelines have been developed to assist physicians in their clinical decisions with regard to Mechanical thrombectomy MT.
Mechanical thrombectomy (MT) has become the cornerstone of acute ischemic stroke management in patients with large vessel occlusion (LVO). Appropriate patient selection and timely reperfusion are crucial. Further randomized trials are needed to inform clinical decision-making with regard to the mothership and drip-and-ship approaches, anaesthesia modalities during MT, and to determine whether MT is beneficial in patients with low stroke severity or large infarct volume.
Main Recommendations
- In adults with anterior circulation large vessel occlusion-related acute ischemic stroke presenting within 6 hours after symptom onset, we recommend mechanical thrombectomy plus best medical management—including intravenous thrombolysis whenever indicated—over best medical management alone to improve functional outcome.
- In adults with anterior circulation large vessel occlusion-related acute ischemic stroke presenting between 6 and 24 hours from time last known well and fulfilling the selection criteria of DEFUSE-3* or DAWN**, we recommend mechanical thrombectomy plus best medical management over best medical management alone to improve functional outcome.
- In patients with large vessel occlusion-related ischemic stroke eligible for both treatments, we recommend intravenous thrombolysis plus mechanical thrombectomy over mechanical thrombectomy alone. Both treatments should be performed as early as possible after hospital arrival. Mechanical thrombectomy should not prevent the initiation of intravenous thrombolysis, and intravenous thrombolysis should not delay mechanical thrombectomy.
- In patients with large vessel occlusion-related ischemic stroke not eligible for intravenous thrombolysis, we recommend mechanical thrombectomy as a stand-alone treatment.
- In patients with suspected stroke, we cannot make a recommendation on the use of a prehospital scale for improving identification of patients eligible for mechanical thrombectomy. We suggest enrolling patients in a dedicated randomized controlled trial, whenever possible.
- We cannot make recommendations on whether for adults identified as potential candidates for mechanical thrombectomy in the prehospital field, the mothership or the drip-and-ship model should be applied to improve functional outcome.
- We recommend that patients aged ≥80 years with large vessel occlusion-related acute ischemic stroke within 6 hours of symptom onset should be treated with mechanical thrombectomy plus best medical management, including intravenous thrombolysis whenever indicated. Application of an upper age limit for mechanical thrombectomy is not justified.
- We suggest that patients aged ≥80 years with large vessel occlusion-related acute ischemic stroke between 6 and 24 hours from time last known well should be treated with mechanical thrombectomy plus best medical management if they meet the eligibility criteria of the DEFUSE-3* or DAWN** trials.
- We do not recommend an upper NIHSS score limit for decision-making on mechanical thrombectomy. We recommend that patients with high stroke severity and large vessel occlusion-related acute ischemic stroke be treated with mechanical thrombectomy plus best medical management, including intravenous thrombolysis whenever indicated. These recommendations also apply for patients in the 6–24 hour time window, provided that they meet the inclusion criteria for the DAWN or DEFUSE-3 studies.
- We recommend that patients with low stroke severity (NIHSS score 0–5) and large vessel occlusion-related acute ischemic stroke within 24 hours from time last known well be included in randomized controlled trials comparing mechanical thrombectomy plus best medical management versus best medical management alone.
- In the 0–6 hour time window, we recommend mechanical thrombectomy plus best medical management (including intravenous thrombolysis whenever indicated) over best medical management alone in patients with large vessel occlusion-related anterior circulation stroke without evidence of extensive infarct core (eg, ASPECTS ≥6 on non-contrast CT scan or infarct core volume ≤70 mL).
- In the 6–24 hour time window, we recommend mechanical thrombectomy plus best medical management (including intravenous thrombolysis whenever indicated) over best medical management alone in patients with large vessel occlusion-related anterior circulation stroke fulfilling the selection criteria of DEFUSE-3* or DAWN**, including estimated volume of infarct core.
- We recommend that patients with anterior circulation stroke with extensive infarct core (eg, ASPECTS <6 on non-contrast CT scan or core volume >70 mL or >100 mL) be included in randomized controlled trials comparing mechanical thrombectomy plus best medical management with best medical management alone.
- In adult patients with anterior circulation large vessel occlusion-related acute ischemic stroke presenting from 0 to 6 hours from time last known well, advanced imaging is not necessary for patient selection.
- In adult patients with anterior circulation large vessel occlusion-related acute ischemic stroke presenting beyond 6 hours from time last known well, advanced imaging selection is necessary.
- In adult patients with large vessel occlusion-related acute ischemic stroke, we recommend treatment in a comprehensive stroke center.
- For adults with large vessel occlusion-related acute ischemic stroke, we recommend that interventionalists should attempt a TICI grade 3 reperfusion, if achievable with reasonable safety.
- There is no evidence that contact aspiration alone improves functional outcome compared with best medical management in patients undergoing mechanical thrombectomy.
- There is no evidence that contact aspiration alone increases the rate of reperfusion over thrombectomy using a stent retriever.
- Therefore, we suggest the use of a stent retriever over contact aspiration alone for mechanical thrombectomy in patients with acute ischemic stroke.
- We cannot provide recommendations to use general anesthesia or conscious sedation in patients undergoing mechanical thrombectomy, due to low quality of evidence and conflicting results between three small single-center randomized clinical trials and the best available observational evidence. Therefore, we recommend the enrollment of patients in multicenter randomized controlled trials addressing this question.
- We suggest keeping blood pressure below 180/105 mmHg during, and 24 hours after, mechanical thrombectomy. No specific blood pressure-lowering drug can be recommended.
- During mechanical thrombectomy, systolic blood pressure drops should be avoided.
- No recommendation can be provided regarding which treatment modality should be favored in patients with large vessel occlusion-related acute ischemic stroke and associated extracranial carotid artery stenosis or occlusion. We recommend the inclusion of such patients in dedicated randomized controlled trials.
For more details click on the link: http://dx.doi.org/10.1136/neurintsurg-2018-014569
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