17
Endovascular Interventions
Î Patients eligible for IV rtPA should receive IV rtPA even if
endovascular treatments are being considered (I-A).
(Unchanged from 2013 guideline)
Î Patients should receive endovascular therapy with a stent retriever if
they meet all the following criteria (I-A) (New recommendation):
• pre-stroke modified Rankin score (mRS) 0-1acute ischemic stroke receiving IV
rtPA within 4.5 hours of onset according to guidelines from professional medical
societies
• causative occlusion of the internal carotid artery or proximal middle cerebral artery
(M1)
• age 18 years and over
• National Institutes of Health Stroke Scale (NIHSS) score of ≥6
• Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 6 or
greater, and
• treatment can be initiated (groin puncture) within 6 hours of symptom onset
Î As with IV rtPA, reduced time from symptom onset to reperfusion
with endovascular therapies is highly associated with better clinical
outcomes. To ensure benefit, reperfusion to TICI grade 2b/3 should
be achieved as early as possible and within 6 hours of stroke onset
(I-B-R). (Revised from 2013 guideline)
Î When treatment is initiated beyond 6 hours from symptom onset, the
benefits of endovascular therapy are uncertain for patients with acute
ischemic stroke who have causative occlusion of the internal carotid
artery or proximal middle cerebral artery (M1) (IIb-C).
(New recommendation from 2013 guideline)
Note: Additional randomized trial data are needed.
Î In carefully selected patients with anterior circulation occlusion who
have contraindications to IV rtPA, endovascular therapy with stent
retrievers completed within 6 hours of stroke onset is reasonable
(IIa-C). (New recommendation from 2013 guideline)
Note: There are inadequate data available at this time to determine the clinical
efficacy of endovascular therapy with stent retrievers for those patients whose
contraindications are time-based or non-time based (such as prior stroke, serious head
trauma, hemorrhagic coagulopathy or receiving anticoagulant medications).
Î 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 hours of symptom onset and who have causative
occlusion of the M2 or M3 portion of the middle cerebral arteries,
anterior cerebral arteries, vertebral arteries, basilar artery or
posterior cerebral arteries (IIb-C).
(New recommendation from 2013 guideline)
