New guidelines for endovascular therapy with emphasis on Class I level a

New Class I level A recommendations for endovascular therapy

 

(1) pre-stroke modified Rankin Score (mRS 0-1)
(2) acute ischemic stroke receiving IV rtPA within 4.5 hours of onset according to guidelines from professional medical societies,
(3) causative occlusion of the internal carotid artery or proximal middle cerebral artery (M1),
(4) age 18 years and over,
(5) National Institutes of Health Stroke Scale (NIHSS) score of 6 or greater,
(6) Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of6 or greater, and
(7) treatment can be initiated (groin puncture) within 6 hours of symptom onset

 

"If endovascular therapy is contemplated, a noninvasive intracranial vascular study is strongly recommended during the initial imaging evaluation of the acute stroke patient but should not delay IV rtPA if indicated. For patients who qualify for IV rtPA according to guidelines from professional medical societies, initiating IV rtPA before non-invasive vascular imaging is recommended for patients who have not had non-invasive vascular imaging as part of their initial imaging assessment for stroke. Non-invasive intracranial vascular imaging should then be obtained as quickly as possible"  (Class I, Level A recommendation)

 

"Regional systems of stroke care should be developed. These should consist of consisting of:
Health care facilities that provide initial emergency care including administration of IV rtPA, including PSCs, CSCs and other facilities
Centers capable of performing endovascular stroke treatment with comprehensive peri-procedural care, including CSC and other health care facilities, to which rapid transport can be arranged when appropriate"

Class 1 Level A evidence

 

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).Additional randomized trial data are needed

 

"It might be reasonable to favor conscious sedation over general anesthesia during endovascular therapy for acute ischemic stroke. However, the ultimate selection of anesthetic technique during endovascular therapy for acute ischemic stroke should be individualized based on patient risk factors, tolerance of the procedure, and other clinical characteristics. Randomized trial data are needed.  (RATES ONLY LEVEL 2B, CLASS C RECOMMENDATION)" (Dr. Tsappidi previously outlined case for anesthesia and our policy is that the interventionist can decide whether to use).