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Introduction
Acute ischemic stroke (AIS) is the fifth leading cause of death, and remains the leading cause of disability in the USA.1 There are an estimated 680 000 new strokes per year in the USA, with a mortality rate of 53–94%, and with an even greater morbidity.2 It is estimated that 3–22% of these patients are candidates for endovascular therapy.3–6 In addition to baseline stroke severity, emergent large vessel occlusion (ELVO) has been shown to be an independent predictor of poor outcome at 6 months.3 4 While intravenous recombinant tissue plasminogen activator (IV r-tPA) has proven efficacious predominantly for small cerebral vessel occlusions, endovascular therapies, including stent retriever based, aspiration based mechanical thrombectomy techniques, and intra-arterial administration of thrombolytic agents, have been shown to achieve higher rates of recanalization in patients with ELVO.7–10 The purpose of this document is to provide an update and critical assessment of technical aspects of the mechanical thrombectomy procedure.
Materials and methods
This document was prepared by the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery (SNIS), a multidisciplinary society representing the leaders in the field of endovascular therapy for cerebrovascular disease. A review of the English language literature published between January 1998 and March 2016 was conducted using search terms that included: ‘stroke,’ ‘ischemic stroke,’ ‘large vessel occlusion,’ ‘thrombectomy,’ ‘mechanical thrombectomy,’ ‘neurointerventional,’ ‘tPA,’ and ‘technique.’ Additionally, we incorporated already existing guidelines published by the American Heart Association (AHA) and the SNIS.11–15 The strength of the evidence supporting each recommendation was summarized using a scale previously described by the AHA guideline panels, and by the University of Oxford, Centre for Evidence Based Medicine .13 15–18
Discussion and recommendations
Much of our current practice in mechanical thrombectomy derives from recent randomized controlled trials (RCTs) which provide a foundation for treatment goals. The online supplementary tables 1-3 provide details of these thrombectomy trials, …
Footnotes
Contributors CDG, FAM, and PIS were the primary authors to contruct the manuscript and provide summaries of relevant data. JFF, as senior author, coordinated the reformatting, revising, and collaboration with the primary authors for review to the Journal of NeuroInterventional Surgery. All other authors represent the combined members of the SNIS Executive Board and Standards & 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 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 in light of 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 Dr Chen reports being a consultant for Medtronic, Penumbra, Stryker and Genentech Dr Fraser is an equity interest holder for Fawkes Biotechnology, LLC, and a consultant for Stream Biomedical. Dr Hetts reports being a consultant for Medina and Neuravi, as well as research contracts with Stryker Neurovascular, Siemens, Micro Vention Terumo. Dr. Klucznik reports being a proctor and speaker for Medtronic. Dr Mocco reports the following: Consultant: Rebound Therapeutics, TSP Inc., Cerebrotech, Lazarus Effect, Pulsar, Medina. investor: Blockade Medical, TSP Inc., Lazarus effect, Medina 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. Dr Prestigiacomo reports the following: Consultant, Codman Neurovascular (serving on DSMB) Dr Pride reports the following: Consultant, Sequent Medical (DSMB for Web-IT study) Dr Sunenshine reports protctoring for Medtronic, and is an investigator in STRATIS (Medtronic) and CARE (Penumbra) studies. All other authors report no relevant conflicts of interest.
Provenance and peer review Not commissioned; externally peer reviewed.