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Prehospital care delivery and triage of stroke with emergent large vessel occlusion (ELVO): report of the Standards and Guidelines Committee of the Society of Neurointerventional Surgery
  1. G Lee Pride1,
  2. Justin F Fraser2,
  3. Rishi Gupta3,
  4. Mark J Alberts4,
  5. J Neal Rutledge5,
  6. Ray Fowler6,
  7. Sameer A Ansari7,
  8. Todd Abruzzo8,
  9. Barb Albani9,
  10. Adam Arthur10,
  11. Blaise Baxter11,
  12. Ketan R Bulsara12,
  13. Michael Chen13,
  14. Josser E Delgado Almandoz14,
  15. Chirag D Gandhi15,
  16. Don Heck16,
  17. Steven W Hetts17,
  18. Joshua A Hirsch18,
  19. M Shazam Hussain19,
  20. Richard Klucznik20,
  21. Seon-Kyu Lee21,
  22. William J Mack22,
  23. Thabele Leslie-Mazwi23,
  24. Ryan A McTaggart24,
  25. Philip M Meyers25,
  26. J Mocco26,
  27. Charles Prestigiacomo27,
  28. Athos Patsalides28,
  29. Peter Rasmussen29,
  30. Robert M Starke30,
  31. Peter Sunenshine31,
  32. Donald Frei32,
  33. Mahesh V Jayaraman33
  34. on behalf of the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery (SNIS)
  1. 1Department of Radiology and Neuroradiology, UT Southwestern Medical Center, Dallas, Texas, USA
  2. 2Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
  3. 3Wellstar Neurosciences Institutes, Wellstar Health System, Kennestone Hospital, Marietta, Georgia, USA
  4. 4Department of Neurology, University of Texas Southwestern Medical Center. Dallas, Texas
  5. 5Brackenridge Medical Center, Austin, USA
  6. 6Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
  7. 7Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois, USA
  8. 8Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
  9. 9Department of Neurointerventional Surgery, Christiana Care Health Systems, Newark, Delaware, USA
  10. 10Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  11. 11Department of Radiology, University of Tennessee Medical Center, Chatanooga, Tennessee, USA
  12. 12Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
  13. 13Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
  14. 14Section of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Consulting Radiologists Ltd, Minneapolis, Minnesota, USA
  15. 15Neurological Institute of New Jersey, New Jersey Medical School, Newark, New Jersey, USA
  16. 16Department of Radiology, Forsyth Medical Center, Winston Salem, North Carolina, USA
  17. 17University of Medicine, Stanford, California, USA
  18. 18Department of Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
  19. 19Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
  20. 20Department of Interventional Neuroradiology, Methodist Hospital Houston, Houston, Texas, USA
  21. 21Department of Radiology, University of Chicago, Chicago, Illinois, USA
  22. 22Department of Neurosurgery, Keck Medicine of USC, Los Angeles, California, USA
  23. 23NeuroEndovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  24. 24Department of Diagnostic Imaging, Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
  25. 25Radiology and Neurological Surgery, Columbia University, New York, New York, USA
  26. 26Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  27. 27Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
  28. 28Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
  29. 29Neurosurgery Department, Cleveland Clinic, Cleveland, Ohio, USA
  30. 30Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
  31. 31Department of Radiology, Banner Univeristy Medical Center, Phoenix, Arizona, USA
  32. 32Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA
  33. 33Warren Alpert School of Medical at Brown University, Providence, Rhode Island, USA
  1. Correspondence to Dr Mahesh V Jayaraman, Warren Alpert Medical School of Brown University, 593 Eddy St, Room 377, Providence, RI 2903, USA; MJayaraman{at}

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Recent randomized clinical trials1–5 established the superiority of endovascular recanalization techniques, specifically mechanical embolectomy, compared with best medical therapy alone for the treatment of patients with emergent large vessel occlusion (ELVO) stroke. ELVO stroke is defined as a stroke secondary to anterior circulation large vessel occlusion (LVO) of the internal carotid, middle cerebral (M1 segments) arteries documented by imaging, without large completed infarct and presenting within 6 hours of symptom onset.6 Given the overwhelming clinical evidence provided by these trials, recent American Heart Association (AHA) guidelines concluded that “embolectomy needs to be performed as rapidly as possible for the greatest clinical benefit, and is best when performed within 6 h from onset of symptoms” (AHA class I, level of evidence A).6 In addition, cost modeling derived from trial outcomes data and claims databases in the USA strongly suggests that cost-effectiveness and an overall societal benefit is associated with investment in access to these endovascular techniques.7 Rapid access to endovascular services depends upon optimization of prehospital stroke care and transport within stroke systems of care, focusing on the unique needs of patients with ELVO through their diagnostic investigation and treatment pathway. The Society of NeuroInterventional Surgery (SNIS) proposed process time metrics for ELVO stroke treatment, including door to IV tissue plasminogen activator (t-PA) of <30 min, comprehensive stroke center (CSC) door to puncture of <60 min, CSC door to recanalization of <90 min and primary stroke certification (PSC) picture to CSC puncture of <90 min.8 Early team awareness of the patient with potential ELVO, coupled with efficient interdisciplinary communication, triage and transport assist in meeting these ideal time metrics, and also contribute to improved clinical outcomes through efficiency gains and maximization of endovascular care delivery.

Materials and methods

The Standards and Guidelines Committee of the SNIS, a multidisciplinary society representing leaders in the field of …

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