Summary of the mechanical thrombectomy section of the American Heart Association/American Stroke Association 2019 update of the 2018 acute ischemic stroke management guidelines (modified from Powers et al 19)
| COR | LOE | |
| 3.7.1 Concomitant with IV alteplase | ||
| 1. Patients eligible for IV alteplase should receive IV alteplase even if MT is being considered | I | A |
| 2. In patients under consideration for MT, observation after IV alteplase to assess for clinical response should not be performed | III: harm | B-R |
| 3.7.2 Zero to six hours after last seen well | ||
| 1. Patients should receive MT with a stent retriever if they meet all the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion of the ICA or MCA segment 1 (M1); (3) age ≥18 years; (4) NIHSS score of ≥6; (5) ASPECTS ≥6; and (6) treatment can be initiated (groin puncture) within 6 hours of symptom onset | I | A |
| 2. Direct aspiration thrombectomy as first-pass MT is recommended as non-inferior to stent retriever for patients who meet all the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion of the ICA or M1; (3) age ≥18 years; (4) NIHSS score of ≥6; (5) ASPECTS ≥6; and (6) treatment initiation (groin puncture) within 6 hours of symptom onset | I | B-R |
| 3. Although benefits are uncertain, MT with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of segment 2 (M2) or segment 3 (M3) of the MCAs | IIb | B-R |
| 4. Although benefits are uncertain, use of MT with stent retrievers may be reasonable for patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have prestroke mRS score >1, ASPECTS <6, or NIHSS score <6, and causative occlusion of the ICA or proximal MCA (M1) | IIb | B-R |
| 5. Although the benefits are uncertain, the use of MT with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the ACAs, vertebral arteries, basilar artery, or PCAs | IIb | C-LD |
| 3.7.3 Six to 24 hours after last seen well | ||
| 1. In selected patients with AIS within 6 to 16 hours of last known normal who have ELVO in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, MT is recommended | I | A |
| 2. In selected patients with AIS within 16 to 24 hours of last known normal who have ELVO in the anterior circulation and meet other DAWN eligibility criteria, MT is reasonable | IIa | B-R |
| 3.7.4 Technique | ||
| 1. Use of stent retrievers is indicated in preference to the MERCI* device | I | A |
| 2. The technical goal of MT should be reperfusion to a mTICI grade 2b/3 angiographic result to maximize the probability of a good functional clinical outcome | I | A |
| 3. To ensure benefit, reperfusion to mTICI grade 2b/3 should be achieved as early as possible | I | A |
| 4. In the 6- to 24-hour MT window evaluation and treatment should proceed as rapidly as possible to ensure access to treatment for the greatest proportion of patients | I | B-R |
| 5. It is reasonable to select an anesthetic technique during EVT for AIS based on individual patient risk factors, technical performance of the procedure, and other clinical characteristics | IIa | B-R |
| 6. The use of a proximal balloon guide catheter or a large-bore distal-access catheter, rather than a cervical guide catheter alone, in conjunction with stent retrievers may be beneficial | IIa | C-LD |
| 7. Treatment of tandem occlusions (both extracranial and intracranial) during MT may be reasonable | IIb | B-R |
| 8. The safety and efficacy of IV glycoprotein IIb/IIIa inhibitors administered during endovascular stroke treatment are uncertain | IIb | C-LD |
| 9. Use of salvage technical adjuncts, including intra-arterial fibrinolysis, may be reasonable to achieve mTICI grade 2b/3 angiographic results | IIb | C-LD |
| 3.7.5 Blood pressure management | ||
| 1. In patients undergoing MT, it is reasonable to maintain the BP at ≤180/105 mm Hg during, and for 24 hours after, the procedure | IIa | B-NR |
| 2. In patients who undergo MT with successful reperfusion, it might be reasonable to maintain BP at a level <180/105 mm Hg | IIb | B-NR |
*Mechanical Embolus Removal in Cerebral Ischemia (MERCI) device.
ACA, anterior cerebral artery; AIS, acute ischemic stroke; ASPECTS, Alberta Stroke Program Early CT Score; BP, blood pressure; COR, class of recommendation; ELVO, emergent large vessel occlusion; EVT, endovascular thrombectomy; ICA, internal carotid artery; LOE, level of evidence; MCA, middle cerebral artery; mRS, modified Rankin Scale; MT, mechanical thrombectomy; mTICI, modified Thrombolysis in Cerebral Infarction; NIHSS, National Institutes of Health Stroke Scale; PCA, posterior cerebral artery.