European Stroke Organisation (ESO) – European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic StrokeEndorsed by Stroke Alliance for Europe (SAFE)

Abstract

Background: Mechanical thrombectomy (MT) has become the cornerstone of acute ischaemic stroke management in patients with large vessel occlusion (LVO). The aim of this guideline document is to assist physicians in their clinical decisions with regard to MT. Methods: These Guidelines were developed based on the standard operating procedure of the European Stroke Organisation and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. An interdisciplinary working group identified 15 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. Results: We found high quality evidence to recommend MT plus best medical management (BMM, including intravenous thrombolysis whenever indicated) to improve functional outcome in patients with LVO-related acute ischaemic stroke within 6 hours after symptom onset. We found moderate quality of evidence to recommend MT plus BMM in the 6-24h time window in patients meeting the eligibility criteria of published randomized trials. These guidelines further detail

Endovascular treatment for acute ischaemic stroke: clinical outcomes under pressure

“…Results of the study by Cho et al . are in accordance with previous literature and highlight further BP and BP variability as important modifiable factors associated with functional outcomes after EVT. The impact of reperfusion outcome, co‐existing stenosis and collateral circulation status on the optimal BP range remains open and needs to be evaluated in future study protocols.…”

“…It is of particular importance that the negative effect of the aforementioned BP parameters in the study by Cho et al . was present only in patients with successful reperfusion after EVT, whereas no association between systolic successive variation and favorable outcomes was detected in patients without substantial reperfusion after EVT. Before formulating any hypothesis for a potential disparity according to reperfusion status, it should be taken into consideration that the lack of effect in patients without successful reperfusion following EVT could be attributed to the limited number of patients having no successful reperfusion ( n = 65) compared with patients with successful reperfusion ( n = 113) after EVT.…”

“…Cho et al . documented an independent association of both higher mean systolic BP and systolic successive variation during the first 24 h following EVT with reduced likelihood of favorable functional outcomes at 3 months after the index event. No significant association of any BP parameter with the risk of symptomatic intracranial hemorrhage after EVT was uncovered, whereas successive variation was the only parameter that was associated with an increased risk of all‐cause 3‐month mortality .…”

“…. The study population included patients with non‐minor AIS (National Institutes of Health Stroke Scale score > 4) due to LVO in the anterior circulation presenting within 8 h from symptom onset and with small to moderate infarct core volumes on baseline diffusion‐weighted magnetic resonance imaging . Cho et al .…”

“…The association between functional outcomes following EVT and the various BP parameters, measured hourly during the first 24 h after admission, was further investigated in the retrospective analysis of 378 patients with LVO by Cho et al [2]. The study population included patients with non-minor AIS (National Institutes of Health Stroke Scale score > 4) due to LVO in the anterior circulation presenting within 8 h from symptom onset and with small to moderate infarct core volumes on baseline diffusion-weighted magnetic resonance imaging [2]. Cho et al [2] documented an independent association of both higher mean systolic BP and systolic successive variation during the first 24 h following EVT with reduced likelihood of favorable functional outcomes at 3 months after the index event.…”