18
Treatment
Î Endovascular therapy with stent retrievers may be reasonable for
some patients under age 18 years with acute ischemic stroke who
have demonstrated large vessel occlusion in whom treatment can be
initiated (groin puncture) within 6 hours of symptom onset, but the
benefits are not established in this age group (IIb-C).
(New recommendation from 2013 guideline)
Î Although the benefits are uncertain, use of endovascular therapy with
stent retrievers may be reasonable for patients with acute ischemic
stroke in whom treatment can be initiated (groin puncture) within 6
hours of symptom onset and who have pre-stroke mRS 1, ASPECTS
score <6 or NIHSS <6 and causative occlusion of the internal carotid
artery or proximal middle cerebral artery (M1) (IIb-B-R).
(New recommendation from 2013 guideline)
Note: Additional randomized trial data are needed.
Î Observing patients following IV rtPA to assess for clinical response
before pursuing endovascular therapy is not required to achieve
beneficial outcomes and is NOT recommended (III-B-R).
(New recommendation from 2013 guideline)
Î Use of stent retrievers is indicated in preference to the MERCI device
(I-A). The use of mechanical thrombectomy devices other than stent
retrievers may be reasonable in some circumstances (IIb-B-NR). (New
recommendation from 2013 guideline)
Î The use of proximal balloon guide catheter or a large bore distal
access catheter rather than a cervical guide catheter alone in
conjunction with stent retrievers may be beneficial (IIa-C).
(New recommendation from 2013 guideline)
Note: Future studies should examine which systems provide the highest recanalization
rates with the lowest risk for non-target embolization.
Î The technical goal of the thrombectomy procedure should be a
TICI 2b/3 angiographic result to maximize the probability of a
good functional clinical outcome. (I-A) Use of salvage technical
adjuncts including IA fibrinolysis may be reasonable to achieve these
angiographic results, if completed within 6 hours of symptom onset
(IIb-BR). (New recommendation from 2013 guideline)
Î Angioplasty and stenting of proximal cervical atherosclerotic stenosis
or complete occlusion at the time of thrombectomy may be considered
but the usefulness is unknown (IIb-C).
(New recommendation from 2013 guideline)
Note: Future randomized studies are needed.
