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Embolectomy for stroke with emergent large vessel occlusion (ELVO): report of the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery
  1. Mahesh V Jayaraman1,
  2. M Shazam Hussain2,
  3. Todd Abruzzo3,
  4. Barbara Albani4,
  5. Felipe C Albuquerque5,
  6. Michael J Alexander6,
  7. Sameer A Ansari7,
  8. Adam S Arthur8,
  9. Blaise Baxter9,
  10. Ketan R Bulsara10,
  11. Michael Chen11,
  12. Josser A Delgado-Almandoz12,
  13. Justin F Fraser13,
  14. Don V Heck14,
  15. Steven W Hetts15,
  16. Michael Kelly16,
  17. Seon-Kyu Lee17,
  18. Thabele Leslie-Mawzi18,
  19. Ryan A McTaggart19,2,
  20. Philip M Meyers20,
  21. Charles Prestigiacomo21,
  22. G Lee Pride22,
  23. Athos Patsalides23,
  24. Robert M Starke24,
  25. Robert W Tarr25,
  26. Don Frei26,
  27. Peter Rasmussen2,
  28. on behalf of the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery (SNIS)
  1. 1Warren Alpert School of Medical at Brown University, Providence, Rhode Island, USA
  2. 2Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
  3. 3Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
  4. 4Department of Neurointerventional Surgery, Christiana Care Health Systems, Newark, Delaware, USA
  5. 5Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  6. 6Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
  7. 7Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  8. 8Department of Neurosurgery, Semmes-Murphey Clinic, Memphis, Tennessee, USA
  9. 9Department of Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA
  10. 10Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
  11. 11Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
  12. 12Department of Interventional Neuroradiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
  13. 13Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
  14. 14Department of Radiology, Forsyth Medical Center, Winston Salem, North Carolina, USA
  15. 15Department of Radiology, UCSF, San Francisco, California, USA
  16. 16Department of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  17. 17Department of Radiology, The University of Chicago, Chicago, Illinois, USA
  18. 18Department of Neurointerventional Service, Massachusetts General Hospital, Boston, Massachusetts, USA
  19. 19Department of Neurosurgery, Cleveland Clinic, Weston, Florida, USA
  20. 20Department of Neurointerventional Surgery, Columbia Presbyterian Hospital, New York, New York, USA
  21. 21Department of Neurological Surgery, Rutgers University – New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
  22. 22Department of Neuroradiology, UT Southwestern, Dallas, Texas, USA
  23. 23Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA
  24. 24Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
  25. 25Department of Radiology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
  26. 26Radiology Imaging Associates, Interventional Neuroradiology, Englewood, Colorado, USA
  1. Correspondence to Dr Mahesh V Jayaraman, Warren Alpert School of Medical at Brown University, Providence, RI 2903, USA; MJayaraman{at}Lifespan.org

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Introduction

Stroke is the leading cause of adult disability in North America and is the fifth most common cause of death.1 ,2 The natural history of patients with acute ischemic stroke and occlusion of a major intracranial vessel such as the internal carotid artery (ICA), middle cerebral artery (MCA), or basilar artery is dismal, with high rates of mortality and low rates of disability-free survival.3 ,4 We introduce the term ‘Emergent Large Vessel Occlusion (ELVO)’ to describe this clinical scenario.

Among acute ischemic stroke, ELVO accounts for the greatest proportion of patients with long-term disability. For the past two decades the use of endovascular therapy has been performed in many centers across the world. The therapies have spanned from infusion of thrombolytic agents5 ,6 to mechanical embolectomy with the introduction of first-generation devices,7 ,8 aspiration-based embolectomy techniques,9 ,10 and the use of stent-retriever based procedures.11 ,12 However, these embolectomy trials were single-arm trials demonstrating safety of the procedure and technique or superiority over another, without direct comparison with standard medical therapy alone.

In the past 3 years, several major trials have been published comparing endovascular therapy with standard medical therapy alone. The purpose of this document is to summarize the results of these trials and synthesize the level of evidence supporting the use of embolectomy in patients with ELVO.

Materials and methods

This document was prepared by the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery, a multidisciplinary society representing the leaders in the field of endovascular therapy for neurovascular disease. The strength of the evidence supporting each recommendation was summarized using a scale previously described by the American Heart Association.

Discussion and recommendations

Role of intravenous thrombolysis

In 1996 the FDA approved the use of recombinant tissue plasminogen activator (tPA) for the treatment of acute ischemic stroke …

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