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Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee
  1. Maxim Mokin1,
  2. Sameer A Ansari2,
  3. Ryan A McTaggart3,
  4. Ketan R Bulsara4,
  5. Mayank Goyal5,
  6. Michael Chen6,
  7. Justin F Fraser7
  8. Society of NeuroInterventional Surgery
    1. 1 Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
    2. 2 Department of Radiology, Neurology, and Neurological Surgery, Northwestern University, Chicago, Illinois, USA
    3. 3 Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
    4. 4 Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
    5. 5 Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
    6. 6 Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
    7. 7 Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
    1. Correspondence to Dr Justin F Fraser, Departments of Neurological Surgery, Neurology, Radiology, and Neuroscience, University of Kentucky, Lexington KY 40536, USA; Jfr235{at}uky.edu

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    Introduction

    This document aims to provide an update on indications for mechanical thrombectomy in acute ischemic stroke (AIS) from emergent large vessel occlusion (ELVO) in the anterior circulation. This reflects new evidence building on the Society of NeuroInterventional Surgery (SNIS) recommendations published in 2015.1 Recommendations herein supersede those of previous SNIS guidelines where overlap exists. Previous publications included an overview of prehospital care, a summary of the role of intravenous (IV) and intra-arterial (IA) therapies, a review of technical aspects of thrombectomy, and initial hospital management.1–3 This guideline focuses on updated indications for thrombectomy of anterior circulation AIS. Evaluation and management of posterior circulation ELVO will be summarized in separate recommendations.

    Materials and methods

    The Standards and Guidelines Committee of the SNIS, a multidisciplinary society representing the leaders in the field of endovascular therapy for neurovascular disease, prepared this document based on a comprehensive review of the available English language literature relating to the topic. Recommendations follow the American College of Cardiology/American Heart Association (ACC/AHA) classification of recommendation/level of evidence and definition of classes and levels of evidence used in American Heart Association/American Stroke Association (AHA/ASA) recommendations.4 Throughout this document, we will refer to the specific selection criteria from the recent randomized trials and registries of modern thrombectomy approaches, which are summarized in table 1.

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    Table 1

    Randomized trials and registries of modern approaches to thrombectomy

    Indications for thrombectomy

    Defining the criteria to evaluate and select patients with ELVO for endovascular treatment is critically important, since between 3% and 22% of patients with AIS are potentially eligible for mechanical thrombectomy, depending on the specific selection criteria used.5–7 Time of symptom onset (or last known well, magnitude of early ischemic change on initial imaging, clinical severity of stroke symptoms, pre-stroke level of functioning and anatomic location of the ELVO are the most important determinants of …

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