Time
< 6 hours
Every large vessel occlusion

6-24 hours + DAWN / DEFUSE
In patients with anterior circulation AIS due to intracranial ICA and/or M1 occlusion within 6–24 hours of symptom onset who meet the advanced MRI DWI-PWI or CTP imaging criteria for DAWN or DEFUSE 3, thrombectomy is indicated

6-24 hours - DAWN / DEFUSE
Thrombectomy may be indicated in carefully selected patients with anterior circulation AIS within 6–24 hours of symptom onset who do not meet imaging criteria for DAWN and DEFUSE 3 but otherwise have a ‘favourable’ imaging profile such as CT ASPECTS of 6–10, MRI DWI ASPECTS of 6–10, moderate-to-good collateral status on mCTA, or small (< 70 mL) core infarct on advanced MRI DWI-PWI or CTP imaging

Location
Thrombectomy is indicated in patients with occlusions of the ICA (including intracranial, cervical segments or tandem occlusion) and M1/M2 MCA

The benefit of thrombectomy in more distal segments, such as MCA M3 or anterior cerebral artery is unclear. Thrombectomy of such patients may be reasonable in some cases and should be considered on a case-by-case basis

Severity
NIHSS > 6
In case of an anterior circulation emergent large vessel occlusion with NIHSS score ≥ 6

NIHSS < 6
When associated with disabling symptoms. However, care should be taken when treating these patients to keep complication and haemorrhagic rates below those reported in RCTs.

Age
Age >80 years should not be used as a contraindication for thrombectomy
The benefit of thrombectomy in patients with baseline mRS score >1 is unknown.

• Contrast allergy

Oxygenation
Supplemental oxygen should be provided to maintain oxygen saturation > 94%

Bloodpressure
In patients for whom mechanical thrombectomy is planned and who have not received IV fibrinolytic therapy, it is reasonable to maintain BP ≤ 185/110 mm Hg before the procedure.

Patients who have elevated BP and are otherwise eligible for treatment with IV alteplase should have their BP carefully lowered so that their SBP is < 185 mm Hg and their diastolic BP is < 110 mm Hg before IV fibrinolytic therapy is initiated.

Hypotension and hypovolemia should be corrected to maintain systemic perfusion levels necessary to support organ function.

Temperature
Sources of hyperthermia (temperature >38°C) should be identified and treated, and antipyretic medications should be administered to lower temperature in hyperthermic patients with stroke.

Blood glucose
Evidence indicates that persistent in-hospital hyperglycemia during the first 24 hours after AIS is
associated with worse outcomes than normoglycemia and thus, it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL and to
closely monitor to prevent hypoglycemia in patients withAIS.

Hypoglycemia (blood glucose <60 mg/dL) should be
treated in patients with AIS.

Alteplase
Patients eligible for IV alteplase should receive IV alteplase even if mechanical thrombectomy is being considered.

For otherwise eligible patients with mild but disabling stroke symptoms, IV alteplase is recommended for patients who can be treated within 3 hours of ischemic stroke symptom onset or patient last known well or at baseline state.

For otherwise eligible patients with mild disabling stroke symptoms, IV alteplase may be reasonable for patients who can be treated within 3 and 4.5 hours of ischemic stroke symptom onset or patient last known well or at baseline state

For otherwise eligible patients with mild non-disabling stroke symptoms (NIHSS score 0-5), IV alteplase is not recommended for patients who could be treated within 3 hours of ischemic stroke symptom onset or patient last known well or at baseline state.

For otherwise eligible patients with mild non-disabling stroke symptoms (NIHSS score 0-5), IV alteplase is not recommended for patients who could be treated within 3 and 4.5 hours of ischemic stroke symptom onset or patient last known well or at baseline state.

IV alteplase for adults presenting with an AIS with known sickle cell disease can be beneficial.

In patients with a hyperdense MCA sign, IV alteplase can be beneficial.

Other anticoagulantia
The efficacy of the IV glycoprotein IIb/IIIa inhibitors tirofiban and eptifibatide co-administered with IV alteplase is not well established.

IV aspirin should not be administered within 90 minutes after start of IV alteplase.

IV alteplase should not be administered to patients who have received a full treatment dose of low-
molecular-weight heparin (LMWH) within the previous 24 hours.

• Ultrasound
• Sterile drapes
• 1% lidocaine

• Oblique prone

• Time out
• Positioning patient
• Sterile wash and drapes
• Ultrasound guided punction

• Use of stent retrievers is indicated in preference to the Mechanical Embolus Removal in cerebral Ischemia (MERCI) device.
• The technical goal of the thrombectomy procedure should be reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 angiographic result to maximize the probability of a good functional clinical outcome.
• To ensure benefit, reperfusion to mTICI grade 2b/3 should be achieved as early as possible within the therapeutic window.
• In the 6-24 hour thombectomy window evaluation and treatment should proceed as rapidly as possible to ensure access to treatment for the greatest proportion of patients.
• Direct aspiration thrombectomy as first pass mechanical thrombectomy 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 internal carotid artery or M1; (3) age ≥18 years; (4) NIHSS score of ≥6; (5) ASPECTS of ≥6; and (6) treatment initiation (groin puncture) within 6 hours of symptom onset.
• It is reasonable to select an anesthetic technique during EVT for AIS on the basis of individualized assessment of patient risk factors, technical performance of the procedure, and other clinical characteristics.
• 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.
• Treatment of tandem occlusions (both extracranial and intracranial occlusions) when performing mechanical thrombectomy may be reasonable.
• The safety and efficacy of IV glycoprotein IIb/IIIa inhibitors administered during endovascular stroke treatment are uncertain.
• Use of salvage technical adjuncts including intra-arterial fibrinolysis may be reasonable to achieve mTICI grade 2b/3 angiographic results.

• Symptomatic cerebral hemorrhage 4.9%
• Air emboli 1.4%
• Emboli to new vascular territory 0.7%
• Serious groin complication 2.8%
• Vessel dissection 3.5%

Antithrombotic Therapy

• Non-cardioembolic AIS

Increasing aspirin dose or switching antiplatelet agents is not well established
SPS-3: no benefit to adding clopidogrel to aspirin
WARSS: no difference in stroke recurrence after switching to warfarin
WASID: no difference after switching to warfarin

Anticoagulation for AIS due to atrial fibrillation
Reasonable to initiate oral anticoagulation 4-14 days after AIS for most patients

• Hemorrhagic transformation

Reinitiation depends on clinical scenario

• Dissection

Antiplatelet or anticoagulation is reasonable (CADISS). If recurrence, the value of intracranial stenting is not well established