European Stroke Organisation (ESO)- European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke

Abstract

BackgroundMechanical thrombectomy (MT) has become the cornerstone of acute ischemic stroke management in patients with large vessel occlusion (LVO). The aim of this guideline document is to assist physicians in their clinical decisions with regard to MT.MethodsThese guidelines were developed based on the standard operating procedure of the European Stroke Organisation, and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. An interdisciplinary working group identified 15 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach.ResultsWe found high quality evidence to recommend MT plus best medical management (BMM, including intravenous thrombolysis whenever indicated) to improve functional outcome in patients with LVO related acute ischemic stroke within 6 hours after symptom onset. We found moderate quality of evidence to recommend MT plus BMM in the 6–24 hour time window in patients meeting the eligibility criteria of published randomized trials. These guidelines further detail aspects of prehospital management, patient selection based on clinical and imaging characteristics, and treatment modalities.ConclusionsMT is the standard of care in patients with LVO related acute stroke. 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, anesthaesia modalities during MT, and to determine whether MT is beneficial in patients with low stroke severity or large infarct volume.

A 10% blood pressure drop from baseline during mechanical thrombectomy for stroke is strongly associated with worse neurological outcomes

“…Indeed, an aggressive treatment of periprocedural BP, defined by (1) a strict BP target during MT, with a more stringent BP cut-off in comparison to current guidelines, (2) the use of vasopressors before recanalization has occurred in the case of GA or CS, and (3) a closer BP monitoring, every 2 min, allowing real-time implementation of hemodynamic treatments, could be as efficient for stroke patients during MT as it is for high-risk patients during major surgeries 21. In the stroke context, one could design a similar study to compare absolute BP thresholds during MT (recommended by the American12 and European guidelines34) versus an individualized strategy in which MAP targets during MT would be within 10% of the baseline MAP measured in the angio suit. This strategy seems attractive because of its individualized and tailored design, in comparison to absolute BP thresholds.…”

CD84 Links T Cell and Platelet Activity in Cerebral Thrombo-Inflammation in Acute Stroke

“…MTE was then indicated based on clinical and radiological criteria recommended by current guidelines. 35 All procedures were performed by board-certified neurointerventional experts or by supervised neurointerventional fellows. A detailed description of the MTE technical procedural steps used in this study is given elsewhere.…”

MeVO: the next frontier?

“…However, it is only recently that innovative postprocessing methods, such as time variant multiphase CT angiography color maps,5 which further facilitate MeVO detection for unexperienced readers, have become available. Since MeVO patients were underrepresented in previous EVT trials (the MulticenterRandomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN) trialwas the only trial that included patients with M2 occlusions, and they constituted only 8% of the trial’s patient population),6 there is no clear guideline based EVT recommendation for MeVO strokes 2 7. We have limited evidence for the safety and efficacy of EVT in M2 occlusions from the HERMES collaboration, but these data are not sufficient to change treatment guidelines.…”

“…Current level 1A EVT recommendations for AIS are restricted to patients with LVO 2 7. Clinical practice however often precedes guideline recommendations.…”