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Is discretion the better part of valor?
  1. Alejandro M Spiotta1,
  2. Adam S Arthur2,
  3. David Fiorella3,
  4. Donald Frei4,
  5. Blaise Baxter5,
  6. J Mocco6,
  7. Joshua A Hirsch7,
  8. Raymond D Turner1,
  9. Aquilla S Turk1
  1. 1 Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  2. 2 Department of Neurosurgery, Semmes-Murphey Clinic, Memphis, Tennessee, USA
  3. 3 Department of Neurosurgery, State University of New York, New York, USA
  4. 4 Department of Neuroradiology, Swedish Medical Center, Englewood, Colorado, USA
  5. 5 Department of Neuroradiology, Erlanger Health System, Chattanooga, Tennessee, USA
  6. 6 Department of Neurosurgery, Mount Sinai Medical Center, New York, USA
  7. 7 Department of Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Alejandro M Spiotta, Department of Neurosurgery, Medical University of South Carolina, Charleston, SC 29425, USA; spiotta{at}

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This is truly a remarkable time for both patients and physicians treating acute ischemic stroke. Patients suffering from an emergent large vessel occlusion (ELVO) have more hope for recovery than ever before. Stroke surgeons are now equipped with safe and effective treatment methods for ELVO patients, backed with overwhelming level 1A evidence. The pool of patients who may receive a benefit from thrombectomy is expanding as patient selection, thrombectomy techniques, and stroke systems of care are further optimized.

The refinement of strategies for thrombectomy has revolutionized our technical approach as stroke surgeons. Gone are the days when thrombectomy procedures would routinely take 2 hours, with less than half of cases achieving successful recanalization. These prolonged procedures often involved progressively more aggressive attempts with multiple devices and, often, the most difficult decision was when to throw in the towel and abort the case in the hopes of avoiding a complication.

The current mindset is entirely different. We start the thrombectomy procedure with the evidence-based expectation that it will be a success. While the drive and motivation of those caring for ELVO patients has not changed, the attitude has drastically improved from defeatist to positive. As the latest data from the COMPASS trial have demonstrated, both aspiration and stent-trievers can be …

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  • Contributors Each author listed should receive authorship credit based on the material contribution to this article, their revision of this article, and their final approval of this article for submission to this journal.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests 880, rEB, Q-Ap,AMS: Penumbra Consulting, Honorarium, Speaker Bureau; Pulsar Vascular Consulting, Honorarium, Speaker Bureau; Microvention Consulting, Honorarium, Speaker Bureau, Research; Stryker Consulting, Honorarium, Speaker Bureau. AST: Codman Consulting, Honorarium, Speaker Bureau, Research Funding; Covidien Consulting, Honorarium, Speaker Bureau; Penumbra Consulting, Honorarium, Speaker Bureau, Research Grants; Microvention Consulting, Honorarium, Speaker Bureau, Research Grants; Blockade – Stock, Consulting, Honorarium, Speaker Bureau; Pulsar Vascular Stock, Consulting, Honorarium, Speaker Bureau, Research; Medtronic Consulting, Honorarium, Speaker Bureau. Codman Consulting, Research Grants; Penumbra Consulting, Research Grants; Microvention Consulting, Research Grants; Blockade – Stock, Consulting; Pulsar Vascular Stock, Consulting, Research Grants; Medtronic Consulting, Research Grants; Siemens Consulting. JM: National/International PI/Co-PI for the following trials: THERAPY (PI), FEAT (PI), INVEST (Co-PI), COMPASS (Co-PI), LARGE (Co-PI), COAST (Co-PI), POSITIVE (Co-PI). He is on the Steering Committee for the MAPS trial. Consultant: Rebound Therapeutics, TSP Inc,. Cerebrotech, Lazarus Effect, Pulsar, Medina; Investor: Blockade Medical, TSP Inc., Lazarus Effect, Medina. JAH: Medtronic Consulting, Codman Neurovascular DSMB service; Neiman Health Policy Institute Grant Institute. BB: Stock, Consultant, Speakers Bureau: Penumbra; Consultant: Medtronic, Stryker, Viz; % Ownership: Route 92. DF: Medical Advisory Board/Consultant/Speakers Bureau: Ceranovus, Genentech, Penumbra, Shape Memory Medical, Stryker; Research Support: Ceranovus, Medtronic, Microvention, Penumbra, Siemens, Stryker; Stock ownership: Penumbra. ASA: Consultant for Johnson and Johnson, Leica, Medtronic, Microvention, Penumbra,Scientia, Siemens, Stryker Research Support from Microvention, Penumbra and Siemens Shareholder Bendit, Cerebrotech, Endostream, Magneto, Neurogami, Serenity, Synchron and Triad Medical. Medtronic (Consultant, Proctoring), Cerenovous (Royalties, Consulting), Microvention (Consulting, Research Support), Vascular Simulations (Board Member, Stockholder), Penumbra (Research Support), Siemens (Research Support), Neurogami (Stockholder). RT: BALT International (Consultant), Blockade Medical (Consultant/Stock), Codman (Transitioning to Cerenovous (Consultant)), Medtronic (Consultant), Microvention-Terumo (Consultant), Penumbra (Consultant) Q’Apal (Consultant) Rebound Tx (Consultant), 880 Medical (Consultant).

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.