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Post-thrombectomy management of the ELVO patient: Guidelines from the Society of NeuroInterventional Surgery
  1. Thabele Leslie-Mazwi1,
  2. Michael Chen2,
  3. Julia Yi3,
  4. Robert M Starke4,
  5. M Shazam Hussain5,
  6. Philip M Meyers6,
  7. Ryan A McTaggart7,
  8. G Lee Pride8,
  9. Sameer A Ansari9,
  10. Todd Abruzzo10,
  11. Barbara Albani11,
  12. Adam S Arthur12,
  13. Blaise W Baxter13,
  14. Ketan R Bulsara14,
  15. Josser E Delgado Almandoz15,
  16. Chirag D Gandhi16,
  17. Don Heck17,
  18. Steven W Hetts18,
  19. Richard P Klucznik19,
  20. Mahesh V Jayaraman7,
  21. Seon-Kyu Lee20,
  22. William J Mack21,
  23. J Mocco22,
  24. Charles Prestigiacomo23,
  25. Athos Patsalides24,
  26. Peter Rasmussen5,
  27. Peter Sunenshine25,
  28. Donald Frei26,
  29. Justin F Fraser27
  30. on behalf of the Standards and Guidelines committee of the Society of NeuroInterventional Surgery (SNIS)
  1. 1 Neurointerventional Service, Massachusetts General Hospital, Boston, Massachusetts, USA
  2. 2 Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
  3. 3 University Illinois at Chicago, Chicago, Illinois, USA
  4. 4 Department of Neurosurgery and Radiology, University of Miami, Miami, Florida, USA
  5. 5 Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
  6. 6 Columbia Presbyterian Hospital, New York, New York, USA
  7. 7 Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
  8. 8 Department of Neuroradiology, University of Texas Southwestern, Dallas, Texas, USA
  9. 9 Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  10. 10 Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
  11. 11 Department of Neurointerventional Surgery, Christiana Care Health Systems, Newark, Delaware, USA
  12. 12 Semmes-Murphey Clinic, Memphis, Tennessee, USA
  13. 13 Department of Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA
  14. 14 Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
  15. 15 Department of Neurointerventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
  16. 16 Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
  17. 17 Department of Radiology, Forsyth Medical Center, Winston Salem, North Carolina, USA
  18. 18 Department of Radiology, University of California in San Francisco, San Francisco, California, USA
  19. 19 Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
  20. 20 The University of Chicago, Chicago, Illinois, USA
  21. 21 Keck School of Medicine, University of Southern California, Los Angeles, California, USA
  22. 22 Mount Sinai School of Medicine, Mount Sinai Health System, New York, New York, USA
  23. 23 East Hanover, New Jersey, USA
  24. 24 New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA
  25. 25 Banner Good Samaritan Medical Center, Phoenix, Arizona, USA
  26. 26 Swedish Medical Center, Denver, Colorado, USA
  27. 27 Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
  1. Correspondence to Dr Justin F Fraser, Department of Neurological Surgery, University of Kentucky, Lexington, KY 40536, USA; Jfr235{at}uky.edu

https://doi.org/10.1136/neurintsurg-2017-013270

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    Introduction

    Recent trials have proven the benefits of endovascular treatment for patients with stroke from emergent large vessel occlusions (ELVOs).1–5 Optimal management of these patients involves attention to pre-procedural, intra-procedural, and post-procedural elements. However, many of the ideal treatment approaches following endovascular stroke therapy remain controversial. This document synthesizes current recommendations from the best available evidence to provide guidance in the post-procedural management of a patient undergoing stroke thrombectomy.

    Materials and methods

    This document was constructed by the Standards and Guidelines Committee of the Society for NeuroInterventional Surgery, a multidisciplinary committee composed of practitioners with backgrounds including neuroradiology, vascular neurosurgery, stroke neurology, and neurocritical care. We reviewed electronic databases for publications related to the management of acute stroke patients post-procedure, using both broad and narrow search terms. We subsequently evaluated those results for papers with randomized clinical results, which were given the highest priority. The remaining papers were assessed on the basis of individual methodology, and recommendations were made based on the data available. In the absence of supporting adequate clinical trial evidence, the committee made consensus recommendations. Each recommendation is graded, where possible, with a level of evidence utilizing the American Heart Association/American Stroke Association grading system.6 This document represents one of a continuum related to acute stroke intervention, including other documents on prehospital management, training standards for thrombectomy, and management of ELVO patients.7–9

    Recommendations

    Post-thrombectomy care environment

    ELVO patients require careful monitoring in a stroke unit or intensive care unit. Stroke units provide dedicated, specialized, multidisciplinary inpatient care for ELVO patients. Patients treated in this environment are more likely to survive, regain independence, and return home than those receiving less organized service.10 Stroke units are characterized by protocol guided care, adherence to guidelines, and coordination of care provided by various services.11–14 Furthermore, a dedicated stroke unit is preferable to a mobile consultative …

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    Footnotes

    • Contributors JFF, as senior author, coordinated the reformatting, revising, and collaboration with the primary authors for review to the Journal of NeuroInterventional Surgery. RMS, MSH, PMM, RAM, GLP, JFF, SA, TA, BA, ASA, BWB, KRB, JEDA, CDG, DH, SWH, RPK, SKL, WJM, JM, CP, AP, PR, PS, and DF represent the combined members of the SNIS Executive Board and the Standards and Guidelines Committee (in addition to the other authors). These two bodies work together to evaluate published literature in the context of clinical practice, to determine the relevance and strength of that literature, and to provide expert opinion in clinical practice guidelines. Each of these authors reviewed the document, made revisions, and offered suggestions as their role as topic experts.

    • Disclaimer This literature review (‘Review’) is provided for informational and educational purposes only. Adherence to any recommendations included in this Review will not ensure successful treatment in every situation. Furthermore, the recommendations contained in this Review should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient considering all the circumstances presented by the individual patient, and the known variability and biological behavior of the medical condition. This Review and its conclusions and recommendations reflect the best available information at the time the Review was prepared. The results of future studies may require revisions to the recommendations in this Review to reflect new data. SNIS does not warrant the accuracy or completeness of the Review and assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this Review or for any errors or omissions.

    • Competing interests MC reports being a consultant for Medtronic, Penumbra, Stryker and Genentech. JEDA reports being a consultant for Medtronic, Penumbra, Sequent Medical and Accriva Diagnostics. JFF is an equity interest holder for Fawkes Biotechnology and a consultant for Stream Biomedical. DH reports being a consultant for Stryker Neurovascular. SWH reports being a consultant for Medina and Neuravi, as well as research contracts with Stryker Neurovascular, Siemens, MicroVention Terumo. Hirsch reports being a consultant for Medtronic. RK reports being a proctor and speaker for Medtronic. JM reports the following: consultant: Rebound Therapeutics, TSP, Cerebrotech, Lazarus Effect, Pulsar, Medina; investor: Blockade Medical, TSP, Lazarus effect, Medina; principal investigator (PI)/co-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). Steering committee for the MAPS trial. CP reports the following: Consultant, Codman Neurovascular (serving on DSMB). GLP reports the following: Consultant, Sequent Medical (DSMB for Web-IT study). PR reports the following: Blockade Medical—Investor, Scientific Advisory Board and Stock Holder; Medtronic—Consultant/Honorarium; Nervive Medical—Scientific Advisory Board and Stock Holder; Perflow Medical—Scientific Advisory Board and Stock Holder; Stryker Neurovascular—Scientific Advisory Board. PS reports protctoring for Medtronic and is an investigator in STRATIS (Medtronic) and CARE (Penumbra) studies.

    • Provenance and peer review Commissioned; internally peer reviewed.

    • Correction notice Since this article was first published the initial A has been added to the author name Sameer Ansari. Dr Ansari’s affiliation has been updated also.