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J Neurointerv Surg. 2017 Mar;9(3):316-323. doi: 10.1136/neurintsurg-2015-011984. Epub 2015 Aug 31.

Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery.

Author information

1
Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
2
Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
3
Department of Neurosurgery, University of Calgary, Calgary, Alberta, Canada.
4
Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA.
5
Department of Neurointerventional Surgery, Christiana Care Health Systems, Newark, Delaware, USA.
6
Department of Neurosurgery, Semmes-Murphey Clinic, Memphis, Tennessee, USA.
7
Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.
8
Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
9
Department of Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA.
10
Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA.
11
Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA.
12
Department of Interventional Neuroradiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.
13
Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA.
14
Radiology Imaging Associates, Interventional Neuroradiology, Englewood, Colorado, USA.
15
Department of Neurological Surgery, Rutgers University-New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.
16
Department of Radiology, Forsyth Medical Center, Winston Salem, North Carolina, USA.
17
Department of Radiology, UCSF, San Francisco, California, USA.
18
Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA.
19
Department of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
20
Department of Interventional Neuroradiology, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA.
21
Department of Radiology, The University of Chicago, Chicago, Illinois, USA.
22
Department of Neurointerventional Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.
23
Department of Neurointerventional Surgery, Columbia Presbyterian Hospital, New York, New York, USA.
24
Department of Neuroradiology, UT Southwestern, Dallas, Texas, USA.
25
Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA.
26
Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
27
Department of Radiology, Banner Good Samaritan Medical Center, Phoenix, Arizona, USA.

Abstract

OBJECTIVE:

To summarize the current literature regarding the initial hospital management of patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO), and to offer recommendations designed to decrease the time to endovascular treatment (EVT) for appropriately selected patients with stroke.

METHODS:

Using guidelines for evidenced-based medicine proposed by the Stroke Council of the American Heart Association, a critical review of all available medical literature supporting best initial medical management of patients with AIS secondary to ELVO was performed. The purpose was to identify processes of care that most expeditiously determine the eligibility of a patient with an acute stroke for interventions including intravenous fibrinolysis with recombinant tissue plasminogen activator (IV tPA) and EVT using mechanical embolectomy.

RESULTS:

This review identifies four elements that are required to achieve timely revascularization in ELVO. (1) In addition to non-contrast CT (NCCT) brain scan, CT angiography should be performed in all patients who meet an institutional threshold for clinical stroke severity. The use of any advanced imaging beyond NCCT should not delay the administration of IV tPA in eligible patients. (2) Activation of the neurointerventional team should occur as soon as possible, based on either confirmation of large vessel occlusion or a prespecified clinical severity threshold. (3) Additional imaging techniques, particularly those intended to physiologically select patients for EVT (CT perfusion and diffusion-perfusion mismatch imaging), may provide additional value, but should not delay EVT. (4) Routine use of general anesthesia during EVT procedures, should be avoided if possible. These workflow recommendations apply to both primary and comprehensive stroke centers and should be tailored to meet the needs of individual institutions.

CONCLUSIONS:

Patients with ELVO are at risk for severe neurologic morbidity and mortality. To achieve the best possible clinical outcomes stroke centers must optimize their triage strategies. Strategies that provide patients with ELVO with the fastest access to reperfusion depend upon detail-oriented process improvement.

KEYWORDS:

Stroke

PMID:
26323793
DOI:
10.1136/neurintsurg-2015-011984
[Indexed for MEDLINE]

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