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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 …

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