"Lying down flat (0°) pre-procedurally is superior to lying at 30° 36."
"Although successful technical clot retrieval is essential, appropriate post-procedure care is also critical to avoid complications."
"Avoiding excessively high blood pressure is important in reducing the risk of secondary haemorrhage. In the acute post-ECR/thrombolysis period, a target BP"
"If critical carotid stenosis (i.e. tandem lesion) has been treated, then more aggressive blood pressure control may be warranted to avoid the possibility of cerebral hyperperfusion as well as haemorrhage 16. There are, however, few universally agreed-upon guidelines, and chosen targets will vary according to pre-procedure blood pressure, anticoagulation, pre-ECR thrombolysis, size of the expected infarct and a variety of other factors."
"Some ECR centres advocate for routine imaging post ECR, such as CT or MRI 24 or 48 hours after ECR. The rationale is evaluation of treatment efficacy, to guide management of secondary prevention (such as excluding haemorrhagic transformation before starting antithrombotic therapy), and assessment for complications 40. In other centres, post-ECR imaging is reserved for patients who develop clinical features worrying for complications."
"Avoiding excessively high blood pressure is important in reducing the risk of secondary haemorrhage. In the acute post-ECR/thrombolysis period, a target BP"
"assess the thrombus occlusion pattern (e.g. presence of the clot meniscus sign, a tapered appearance suggestive of underlying intracranial atherosclerotic disease, a cut-off appearance, or a tram-track appearance) 26"
"Certain situations, such as tandem lesions or symptomatic intracranial atherosclerotic disease, may require immediate platelet inhibition during the procedure 37. This need primarily arises from the necessity for stent placement and the associated risk of endothelial damage 37. In these cases, antiplatelet therapy such as intravenous P2Y12 inhibitors (e.g. cangrelor) or intravenous GP IIb/IIIa inhibitors (e.g. tirofiban) may be used 37."
"Avoiding excessively high blood pressure is important in reducing the risk of secondary haemorrhage. In the acute post-ECR/thrombolysis period, a target BP"
"higher baseline NIHSS"
"in patients with high NIHSS score, poor collaterals or low ASPECT score"
Expected headings
"History"
"Patient selection"
"Preprocedural evaluation"
"Positioning"
"Patient positioning"
"Equipment"
"Anaesthetic"
"Intraprocedural antiplatelet therapy"
"Blood pressure control"
"Puncture site"
"Anticoagulation"
"Postprocedural imaging"
"Endovascular clot retrieval (ECR), also known as mechanical thrombectomy (MT) or endovascular thrombectomy (EVT), is increasingly performed in patients presenting with large vessel occlusion (LVO), especially those with a large ischaemic penumbra that is likely to progress to ischaemic stroke. To be successful, careful patient selection and dedicated training and equipment are necessary."
"ECR and its efficacy in ischaemic stroke have been explored since 2005; initial trials revealed disappointing results. This was attributed to an inability to confirm large vessel occlusions radiologically, combined with insufficiently developed devices and treatment delays 18. In 2015, multiple randomised controlled trials were published showing improved clinical outcomes in patients with acute ischaemic stroke due to large vessel occlusion undergoing ECR compared to medical treatment alone 3-5. As a result of these trials, ECR has now become the standard of care for large vessel occlusion strokes involving the anterior circulation."
"acute ischaemic stroke due to medium vessel occlusion (MeVO) has had mixed negative 30,31 and positive 14 trials regarding whether endovascular clot retrieval is superior to best medical therapy; thus, local institutional practice may vary"
"Either sedation or a general anaesthetic can be employed 11. One randomised controlled trial of patients with ischaemic stroke due to large vessel occlusion found general anaesthesia to have superior outcomes compared to moderate sedation 38; however, evidence is overall mixed 11,32, and thus, individual institutional practice may vary."
"Avoiding excessively high blood pressure is important in reducing the risk of secondary haemorrhage. In the acute post-ECR/thrombolysis period, a target BP"
"various patient factors (e.g. premorbid functional status, advance directives, etc.)"
"Non-contrast enhanced CT is used to exclude haemorrhage, and CT angiography to determine large or medium vessel occlusion. Alternatively, MRI and DSA may also demonstrate the occlusion, although the former is less commonly utilised for this due to difficulty with timely access to acute MRI in most institutions. CT perfusion is also important to determine the infarct core and penumbra size, especially in cases performed beyond 6 hours 6,13,20,21."
"can occur before, during or after ECR"
"If critical carotid stenosis (i.e. tandem lesion) has been treated, then more aggressive blood pressure control may be warranted to avoid the possibility of cerebral hyperperfusion as well as haemorrhage 16. There are, however, few universally agreed-upon guidelines, and chosen targets will vary according to pre-procedure blood pressure, anticoagulation, pre-ECR thrombolysis, size of the expected infarct and a variety of other factors."
"Groin site neurovascular observations and bed rest are required as usual. There is an increased move towards radial artery access for lower complication rates 17."
"If critical carotid stenosis (i.e. tandem lesion) has been treated, then more aggressive blood pressure control may be warranted to avoid the possibility of cerebral hyperperfusion as well as haemorrhage 16. There are, however, few universally agreed-upon guidelines, and chosen targets will vary according to pre-procedure blood pressure, anticoagulation, pre-ECR thrombolysis, size of the expected infarct and a variety of other factors."