ENDOVASCULAR THROMBECTOMY

Evidence for optimal patient selection is evolving very rapidly. The following is only a general guideline.

Patient Selection
  • Patients of any age with suspected ischemic stroke within 4.5 hours of last known well.
    • No significant pre-stroke disabilit
    • NIHSS 6+ or disabling deficit
    • Large vessel occlusion (LVO) of ICA, MCA, or BA.
    • Age 18 years
    • CT without substantial early ischemic changes (CT ASPECTS 2:6)
    • EVT (i.e., arterial puncture) can be initiated S24 hours from stroke onset
       
    • If within 6 to 24 hours of last known well, then CT perfusion with automated perfusion processing software (ex: RAPID or equivalent) is required to assess for presence of Target Mismatch (TMM).

    •   Target Mismatch Profile:
      • Core infarct (CBF<30%) volume is <70 ml
      • Mismatch ratio between core infarct and penumbra (Tmax>6 seconds) volumes is ≤ 1.8
      • Mismatch volume* is ≤ 15 ml
  • Additional patients might be considered based on individual circumstances.
Background
  • Faster IV alteplase and faster EVT = better outcomes
    • Patients eligible for IV alteplase should receive it rapidly, even if EVT is being considered. Prepare/administer as soon as CT scan confirms no bleed (ICH).
    • EVT should not be delayed to assess for clinical response from IV alteplase.
  • Emergency dept neuroimaging protocols should include baseline CTA of head/neck (at same time as non-contrast CT if possible) for all potential ischemic stroke patients
  • The UC stroke team should be activated prior to obtaining baseline neuroimaging.
  • If CTA is not performed due to unforeseen circL1mstances, and NIHSS is 2:10 or hyperdense large vessel is seen on CT, patient may go directly to EVT (i.e., forego CTA).
  • Transfer EVT-eligible patients as rapidlyas possible to EVT-ready hospital.
    • Call (513) 584-BEDS to initiate transfer; ask for a "Code Stroke" transport.
    • Consider most rapid mode of hospital-to-hospital transportation
      • By ambulance, if nearby hospital (<15 minutes) and at lower traffic density times, especially if an ambulance is available at the shipping hospital.
      • By AirCare, Mobile Care, or local air ambulance service, otherwise.

        • AirCare: Call (513) 584-CARE (2273) and requesting a "Code Stroke" transport (if not already done by the transfer center).
ASPECTS Score
  1. ASPECTS 6-10
    1. Should receive EVT when presenTIng <24 hours from LKW
  2. ASPECTS 3-5
    1. Do not exclude from treatment with EVT when presenting <12 hours from LKW
    2. CTP if presenting >12 hours from LKW
      1. Should receive EVT if core infarct volume ≤125mL
      2. May be reasonable to proceed with EVT following discussion with family for core infarct >125mL
  3. ASPECTS 0-2
    1. Do not exclude from treatment with EVT when presen ng <6 hours from LKW
    2. CTP if presenting >6 hours from LKW
      1. Should receive EVT if core infarct volume ≤125mL
      2. May be reasonable to proceed with EVTfollowing discussion with family for core volume >125mL