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Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery
  1. Ryan A McTaggart1,
  2. Sameer A Ansari2,
  3. Mayank Goyal3,
  4. Todd A Abruzzo4,
  5. Barb Albani5,
  6. Adam J Arthur6,
  7. Michael J Alexander7,
  8. Felipe C Albuquerque8,
  9. Blaise Baxter9,
  10. Ketan R Bulsara10,
  11. Michael Chen11,
  12. Josser E Delgado Almandoz12,
  13. Justin F Fraser13,
  14. Donald Frei14,
  15. Chirag D Gandhi15,
  16. Don V Heck16,
  17. Steven W Hetts17,
  18. M Shazam Hussain18,
  19. Michael Kelly19,
  20. Richard Klucznik20,
  21. Seon-Kyu Lee21,
  22. Thabele Leslie-Mawzi22,
  23. Philip M Meyers23,
  24. Charles J Prestigiacomo15,
  25. G Lee Pride24,
  26. Athos Patsalides25,
  27. Robert M Starke26,
  28. Peter Sunenshine27,
  29. Peter A Rasmussen18,
  30. Mahesh V Jayaraman1
  31. on behalf of the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery (SNIS)
  1. 1Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
  2. 2Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  3. 3Department of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
  4. 4Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
  5. 5Department of Neurointerventional Surgery, Christiana Care Health Systems, Newark, Delaware, USA
  6. 6Department of Neurosurgery, Semmes-Murphey Clinic, Memphis, Tennessee, USA
  7. 7Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
  8. 8Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, 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. 14Radiology Imaging Associates, Interventional Neuroradiology, Englewood, Colorado, USA
  15. 15Department of Neurological Surgery, Rutgers University—New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
  16. 16Department of Radiology, Forsyth Medical Center, Winston Salem, North Carolina, USA
  17. 17Department of Radiology, UCSF, San Francisco, California, USA
  18. 18Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
  19. 19Department of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  20. 20Department of Interventional Neuroradiology, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
  21. 21Department of Radiology, The University of Chicago, Chicago, Illinois, USA
  22. 22Department of Neurointerventional Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
  23. 23Department of Neurointerventional Surgery, Columbia Presbyterian Hospital, New York, New York, USA
  24. 24Department of Neuroradiology, UT Southwestern, Dallas, Texas, USA
  25. 25Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA
  26. 26Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
  27. 27Department of Radiology, Banner Good Samaritan Medical Center, Phoenix, Arizona, USA
  1. Correspondence to Dr Ryan A McTaggart, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA; ryan.mctaggart{at}lifespan.org

Abstract

Objective To summarize the current literature regarding the initial hospital management of patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO), and to offer recommendations designed to decrease the time to endovascular treatment (EVT) for appropriately selected patients with stroke.

Methods Using guidelines for evidenced-based medicine proposed by the Stroke Council of the American Heart Association, a critical review of all available medical literature supporting best initial medical management of patients with AIS secondary to ELVO was performed. The purpose was to identify processes of care that most expeditiously determine the eligibility of a patient with an acute stroke for interventions including intravenous fibrinolysis with recombinant tissue plasminogen activator (IV tPA) and EVT using mechanical embolectomy.

Results This review identifies four elements that are required to achieve timely revascularization in ELVO. (1) In addition to non-contrast CT (NCCT) brain scan, CT angiography should be performed in all patients who meet an institutional threshold for clinical stroke severity. The use of any advanced imaging beyond NCCT should not delay the administration of IV tPA in eligible patients. (2) Activation of the neurointerventional team should occur as soon as possible, based on either confirmation of large vessel occlusion or a prespecified clinical severity threshold. (3) Additional imaging techniques, particularly those intended to physiologically select patients for EVT (CT perfusion and diffusion–perfusion mismatch imaging), may provide additional value, but should not delay EVT. (4) Routine use of general anesthesia during EVT procedures, should be avoided if possible. These workflow recommendations apply to both primary and comprehensive stroke centers and should be tailored to meet the needs of individual institutions.

Conclusions Patients with ELVO are at risk for severe neurologic morbidity and mortality. To achieve the best possible clinical outcomes stroke centers must optimize their triage strategies. Strategies that provide patients with ELVO with the fastest access to reperfusion depend upon detail-oriented process improvement.

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