Treatment
Endovascular Interventions
ÎÎPatients eligible for IV rtPA should receive IV rtPA even if intraarterial treatments are being considered (I-A).
ÎÎIntra-arterial fibrinolysis is beneficial for treatment of carefully
selected patients with major ischemic strokes of <6 hours' duration
caused by occlusions of the middle cerebral artery who are not
otherwise candidates for IV rtPA (I-B).
Note: The optimal dose of intra-arterial rtPA is not well established, and rtPA does
not have FDA approval for intra-arterial use.
ÎÎAs with IV fibrinolytic therapy, reduced time from symptom onset
to reperfusion with intra-arterial therapies is highly correlated with
better clinical outcomes. All efforts must be undertaken to minimize
delays to definitive therapy (I-B).
ÎÎIntra-arterial treatment requires the patient to be at an experienced
stroke center with rapid access to cerebral angiography and qualified
interventionalists. Expeditious assessment and treatment is critical.
Facilities are encouraged to define criteria that can be used to
credential individuals who can perform intra-arterial revascularization
procedures. Track outcomes on all patients (I-C).
ÎÎWhen mechanical thrombectomy is pursued, stent retrievers such as
Solitaire FR and Trevo are generally preferred to coil retrievers such
as Merci (I-A).
Note: The relative effectiveness of the Penumbra System versus stent retrievers is not
yet characterized.
ÎÎThe Merci, Penumbra System, Solitaire FR, and Trevo thrombectomy
devices can be useful in achieving recanalization alone or in
combination with pharmacologic fibrinolysis in carefully selected
patients (IIa-B).
Note: Their ability to improve patient outcomes has not yet been established. These
devices should continue to be studied in randomized controlled trials to determine the
efficacy of such treatments in improving patient outcomes.
ÎÎIntra-arterial fibrinolysis or mechanical thrombectomy is reasonable
in patients who have contraindications to the use of IV fibrinolysis
(IIa-C).
ÎÎRescue intra-arterial fibrinolysis or mechanical thrombectomy may be
reasonable approaches to recanalization in patients with large-artery
occlusion who have not responded to IV fibrinolysis. (IIb-B)
Note: Additional randomized trial data are needed.
ÎÎThe usefulness of mechanical thrombectomy devices other than the
Merci retriever, the Penumbra System, Solitaire FR, and Trevo is not
well established (IIb-C).
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Note: These devices should be used in the setting of clinical trials.
