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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3657_Библиотеки_им_академика_М_И_Перельмана.pdf
45 Stroke
501
Non-Contrast CT
Hemorrhagic
Medical management
Multilobar infarction >
1/3 cerebral
hemisphere
Medical management
Identifiable core
infarct
< 3 - 4.5 hours since
symptom onset
< 6 hours since
symptom onset
<1/3 cerebral
hemisphere
involvement
> 4.5 hours since
symptom onset
Ischemic
No identifiable core
infarct
> 6 hours since
symptom onset
Medical management
IV TPA CTA
Large vessel
occlusion
Endovascular
therapy
No large vessel
occlusion
Medical management
Fig. 45.1 Stroke treatment algorithm for hemorrhagic and ischemic strokes encompassing medical and endovascular management
502
C. Kim and M. E. Jensen
Conventional Therapy
Vital sign stabilization as well as airway, breathing, and circulation management is paramount in maintaining the acute
stroke patient. Hypoventilation in the setting of a decreased
respiratory drive may lead to retained carbon dioxide and
increasing cerebral vasodilation resulting in elevated intracranial pressures. Impaired cerebral autoregulation is also
present in the setting of acute ischemic stroke and blood
pressure regulation is critical, particularly in patients eligible
for thrombolytic or endovascular therapy. Consensus guidelines recommend a systolic blood pressure<185mm Hg and
a diastolic blood pressure <110mm Hg with blood pressure
of at least 180/105mm Hg 24h after therapy. In patients not
eligible for thrombolytic or endovascular therapy, a systolic
blood pressure <220 mm Hg and a diastolic blood pressure<140mm Hg are recommended [8, 9]. In either case, the
acute stroke patient will require careful surveillance for
worsening cerebral edema, hemorrhagic conversion, and
vasospasm.
Intravenous recombinant tissue plasminogen activator (rtPA) was the earliest recognized treatment for acute ischemic
stroke. In 1995, the National Institute of Neurological
Disorders and Stroke (NINDS) rt-PA Stroke Study Group
trial established the efcacy of IV rt-PA administration
(0.9mg/kg, maximum 90mg) as a thrombolytic in improving NIHSS scores when administered within 3h of symptom
onset [10]. However, no mortality benet was identied, and
the major adverse event was a statistically signicant increase
in intracranial hemorrhage present at both 36-h and 90-day
surveillance. In 2008, the ECASS III trial demonstrated the
effectiveness of IV rt-PA therapy in certain populations up to
4.5h after stroke onset symptoms (Table45.3) [11].
Key Point
Eligibility for IV rt-PA:
• Age≥18
• Clinical ndings of ischemic stroke causing measurable neurologic decit
• Time of symptom onset established to be <180min
before treatment
In 2013, the AHA/ASA published guidelines for the early
management of patients with acute ischemic stroke [9].
These evidence-based recommendations direct care throughout the patient’s admission. Intravenous rt-PA is recommended for patients who meet eligibility criteria and are
within the 0- to 3-h window. Patients within the 3- to 4.5-h
Table 45.3 Absolute contraindications to IV rt-PA administration for
acute ischemic stroke
Intracranial hemorrhage on noncontrast CT
Clinical suspicion of subarachnoid hemorrhage
Multilobar infarction (hypodensity greater than 1/3 cerebral
hemisphere) on CT
History of intracranial hemorrhage/stroke
Uncontrolled hypertension with SBP>185mm hg or
DBP>110mm hg
Known arteriovenous malformation, neoplasm, or aneurysm
Witnessed seizure at stroke onset
Acute bleeding
Major intracranial or spinal surgery, head trauma, or prior stroke
within the past 3months
Arterial puncture at non-compressible site within last 7days
time window may be treated provided they are not older than
80years old, diabetic, or have a previous history of stroke. In
2015 an updated guideline was published [12] specically to
address the role of endovascular treatment in patients with
acute ischemic stroke. Patients who are eligible for IV rt-PA
should receive it even if they are also eligible for an endovascular procedure.
Interventional Therapy
The evolution of endovascular stroke treatment began in the
early 1990s, as the seminal NINDS IV rt-PA trial was well
under way. The results of that trial established IV rt-PA as
the standard of care in eligible stroke patients presenting in
the 0–3-h time window. Endovascular trials became focused
on enrolling patients suspected of having a large vessel
occlusion (LVO) who presented within the 3- to 6-h time
window. Various therapeutic schemes were investigated
including intra-arterial administration of thrombolytics after
receiving a bridging dose of IV rt-PA (IMS I–II) [13, 14] or
as a stand- alone therapy (PROACT I, PROACT II, MELT)
[15–17], the use of novel thrombectomy devices (MERCI,
PIVOTAL, SWIFT, TREVO-2) [18–21], and a combination
of device and thrombolytic use (Multi-MERCI) [22].
Whereas statistically signicant recanalization of the vessel
was often achieved in these trials, none showed a clear benet in clinical outcomes with the exception of the PROACT
II study.
The largest and most ambitious trial—the Interventional
Management of Stroke Trial (IMS III) [23]—was a prospective, randomized trial of IV rt-PA versus intra-arterial therapy in eligible patients presenting within the 0–3-h time
window. Participants who were thought to have an LVO
based upon their NIHSS score (greater than or equal to ten)
were randomized to full-dose IV rt-PA or to low-dose IV
45 Stroke
503
rt-PA followed by intra-arterial rt-PA.Enrollment began in
2006, and the use of thrombectomy devices was allowed as
the trial advanced. However, in 2012, the trial was stopped
when the pre-specied boundary for futility was crossed;
the trial failed to show a benet in functional outcome with
the use of endovascular therapy compared to IV rt-PA alone.
Two other prospective, randomized endovascular trials
reported in 2013—MR RESCUE [24] and SYNTHESISExpansion [25]—also failed to show benet in the intervention arm.
The failure of these trials was a blow to the endovascular
treatment of ischemic stroke, but several lessons were
learned. As devices improved over the years, so did imaging
techniques such as CTA/CT perfusion and MRA/MR perfusion which allowed rapid evaluation of the arterial tree and
determination of core infarct/ischemic penumbra size. The
newest devices such as stentrievers were more efcient and
effective in removing thrombus and reestablishing ow.
Stroke systems of care were optimized to rapidly identify
and mobilize appropriate candidates, thus decreasing the
“time to treat.”
In the rst half of 2015, ve randomized control trials
decisively established the role of intra-arterial treatment for
ischemic strokes caused by large vessel occlusions.
• The rst published trial to show the benet of mechanical
thrombectomy in terms of functional outcomes at 90days
was MR CLEAN [26].
• The EXTEND-IA trial used perfusion imaging to select
patients with small core infarcts [25].
• The ESCAPE trial emphasized decreasing the “door-to-
puncture” time while using multiphase CTA to select
patients based upon ASPECTS score and collateral circu-
lation [28].
• SWIFT-PRIME focused on the use of a specic sten-
triever for thrombectomy in patients who also received IV
rt-PA versus IV rt-PA alone [29].
• REVASCAT demonstrated that mechanical thrombec-
tomy was effective in patients up to 8 h after symptom
onset [30].
The results of the DAWN trial, reported in 2017, extended
the time window for endovascular stroke treatment to 24 h
[31]. In this prospective trial, symptomatic patients with onset
of symptoms within 6 to 24h, and who demonstrated a LVO
with a clinical-imaging mismatch as dened by age, core
infarct size, and NIHSS score, were randomized to best medical therapy or stentriever thrombectomy. Enrollment was
stopped early when the intervention group showed improvement in clinical outcomes at 90 days with a higher rate of
functional independence (modied Rankin scale 0–2) com-
Table 45.4 2015 AHA/ASA patient selection guidelines for endovas-
cular treatment of patients with acute ischemic stroke
Patient selection guidelines
Pre-stroke mRS 0–1
Age≥18
NIHSS ≥6
ASPECTS score ≥6
Acute ischemic stroke receiving IV rt-PA within 4.5h of onset
Causative occlusion of ICA or proximal MCA
Time to puncture within 6h of symptom onset
Abbreviations: mRS modied Rankin score, ICA internal carotid artery,
MCA middle cerebral artery
pared to standard medical therapy (48.6% versus 13.1%). It is
anticipated that many patients with “wake-up strokes,” i.e.,
patients who go to sleep normal but awaken with stroke
symptoms, will be treated in the future.
The ultimate goal of endovascular stroke therapy is to
identify and treat appropriate patients in as rapid a manner as
possible. In general, patients are included or excluded using
pre-specied criteria based on multi-trial data and published
guidelines (Table 45.4) [12]. Selection elements often
include patient age, time last known well, pretreatment
NIHSS, ASPECTS score, premorbid modied Rankin score,
location of thrombus, and symptom onset to expected groin
puncture time. Target times for specic tasks, such as 60min
from “picture to puncture,” should be set and included in
quality assurance data collection.
Rapid treatment of stroke patients requires a multidisciplinary approach utilizing a stroke team to ensure that the
appropriate members are notied in an expedited manner.
The workow process can be streamlined in various ways:
Emergency Department (ED) prenotication of potential
stroke patients; parallel performance of tasks by the stroke,
endovascular, ED, and anesthesia teams; pre-planning of the
procedure using CTA data; and identication of shortcuts,
such as procedural tray preparation prior to team arrival [32].
Use of general anesthesia (GA) is controversial. A recent
meta-analysis found that patients treated under GA had signicantly higher morbidity and mortality rates compared
with non-GA patients [33]. Most of these 22 studies did not
randomize patients by anesthesia type; however, in the three
studies that did randomize, there was either no difference or
better clinical outcomes in the GA group. In those trials,
patients were managed by specialized anesthesia teams with
less than a 10-min delay in puncture time and very low rates
of procedural hypotension [33]. The potential advantages of
GA are reduced patient movement, shorter procedure time,
and improved recanalization rates [34, 35]. Treatment teams
should decide prospectively as to the use of GA in their workow process and staff appropriately.
504
C. Kim and M. E. Jensen
The How To
1. Careful evaluation of the noninvasive imaging
streamlines the endovascular procedure
45.2a, 45.3b, and 45.4a–c). Evaluation of
the aortic arch and brachiocephalic vessels, visualization of the targeted parent artery and collateral circulation, and determination of the size,
number, and location of emboli allow the operator
to choose the appropriate equipment and devices
prior to puncture. Assembling the embolectomy
system before the patient reaches the angiography
suite can save considerable time.
2. Most stroke interventions are performed through
the femoral approach. Use of the radial or brachial
artery may limit catheter size, and treatment of
cult in select patients with variant supra-aortic
branch anatomy.
3. Using standard single-wall puncture technique,
an 8F or larger femoral sheath is used for access.
This size sheath is suitable for passage of most
large- bore guide catheters that will be placed in
the common carotid or subclavian artery.
Alternatively, a long guide sheath or guide catheter (with the exception of balloon-tipped guide
catheters) can be placed directly through the
femoral artery and into the parent vessel. All
guides, sheaths, and catheters are attached to
ture site should be monitored periodically for
hematoma development, particularly in patients
at the discretion of the operator as many of these
patients are on antiplatelet or anticoagulation
agents at presentation.
4. Thrombectomy is achieved using a triaxial catheter
system consisting of a large-bore guide catheter or
guide sheath (usually 6F or larger), a large-bore
aspiration catheter (usually >5F), and a microcatheter of suitable size for passage of a thrombectomy
45.2d, 45.3g, and 45.4h).
5. Initially the guide catheter or sheath is advanced
into the parent vessel over a 5F or 6F diagnostic
catheter suitable for brachiocephalic catheterization, e.g., vertebral catheter. It must be of a suit-
enough length to advance it over a 0.035" guidewire into the parent vessel. The guide can then be
advanced over the diagnostic catheter and placed
in a safe and stable extracranial position.
6. An initial cervicocerebral angiogram of the target
vessel is done to evaluate the arterial anatomy;
determine the size, location, and extent of the
thrombus; and visualize the cerebral perfusion
collaterals. A pretreatment mTICI (modified thrombolysis in cerebral infarction) score is assigned
based upon the cerebral perfusion pattern [36]
45.5
therapeutic goal as it is associated with the probability of a good clinical outcome.
7. The large-bore aspiration catheter is inserted into
the guide. Through the aspiration catheter, the
microcatheter is advanced intracranially over the
microwire using roadmap guidance.
-
8. The microcatheter is placed at the face of the
thrombus, and the aspiration catheter is pushed
over the microsystem until it engages the throm-
45.2d–e). If more purchase is needed, the
microwire is manipulated through the thrombus
into a distal branch. This maneuver is made
blindly, and the operator must be very familiar
with the appearance of and tactile feedback from
catheterization of these vessels.
9. When performing suction thrombectomy (ADAPT
45.2) [37], once the aspiration
catheter has engaged the thrombus, the microcatheter and microwire are removed. Suction is applied
-
to the aspiration catheter, either with an aspiration
the thrombus is adequately engaged, there will be
no blood return or only small bubbles indicating a
vacuum seal. Suction is applied for a few minutes,
and the aspiration catheter is slowly withdrawn.
(a) If a balloon-tipped guide catheter is used,
vessel occlusion prior to aspiration catheter
withdrawal [44].
10. If brisk blood return occurs with suction, the
thrombus has either been dislodged from the catheter tip or has been wholly aspirated into the
syringe or pump reservoir. If the vacuum seal is
maintained, the thrombus is either in the aspiration
catheter or wedged in its tip. The catheter is gently
withdrawn into the guide catheter while suction is
applied to the sidearm on the rotating hemostatic
valve (RHV) attached to the guide.
(a) If the operator is concerned that the thrombus
will shear off if retrieved into the guide, then
the entire system is removed from the parent
artery. This situation is uncommon but most
45 Stroke
embolus has been captured.
11. Once inside the guide catheter, the RHV is
detached from the guide hub so the aspiration
catheter can be removed without dislodging
thrombus in it.
12. An angiographic run is performed through the
45.2f,g,
45.3h, and 45.4i, j).
13.
reassembled, and another aspiration pass is made.
45.2f) and distal
emboli are often not retrieved as the risks out-
505
Stentrievers are more likely to successfully navigate acute angulations of the M2 branch vessel as
the delivery microcatheter is smaller and more
41 45.3g). Fibrotic clot may be
captured by trapping it between the tip of the aspiration catheter and a stentriever and then withdrawing the entire system into the guide catheter.
The aspiration catheter may not advance around a
tortuous cavernous segment or perch on the origin
of the ophthalmic artery. In these situations, the
stentriever can be deployed in the MCA trunk and
used as an anchor to advance the larger catheter to
the face of the clot.
16. In order to reach the intracranial lesion, the extra-
14. 45.3 and
45.4) [38] are the same as suction thrombectomy
with the exception that the microcatheter is also
passed through the thrombus and into one of the
distal branches.
(a) The microwire is removed and replaced with
the stentriever which is positioned within the
distal aspect of the microcatheter where it
spans the thrombus.
(b) The microcatheter is withdrawn over the sten-
triever, unsheathing it within the thrombus
45.3g
angiographic run is performed to demonstrate
vessel recanalization. The stentriever/microcatheter system can then be withdrawn as a
unit into the aspiration catheter and removed.
(c) Alternatively, suction is applied to the sidearm
of the aspiration catheter while the stentriever
is withdrawn into the catheter (Solumbra tech-
39]. To optimize the
effectiveness of the suction, the microcatheter
catheter before the device is extracted.
(d) Another technique used with “closed-cell”
retrievers involves unsheathing the distal part
of the stentriever and then advancing the
device forward to attain better clot adherence
through superior wall apposition (push and
40].
15. Multiple techniques are often used in a single
case. Suction thrombectomy is very effective for
large amounts of thrombus, but the aspiration
catheter may be too large for branch vessels.
passage of the thrombectomy system. Tw o strategies have been employed—angioplasty of the
extracranial vessel with or without stent place-
retrieval of the thrombus followed by treatment of
the cervical lesion. Most operators favor the former strategy as it increases perfusion pressure,
nous thrombolysis [38, 42, 43].
(a) For atherosclerotic lesions, angioplasty alone
acute stroke phase, with stenting or endarterectomy performed after the risk of reperfusion hemorrhage has decreased.
(b) Carotid dissections are more challenging as
the true lumen is compressed by subintimal
thrombus, often along the length of the vessel.
prevents thrombus migration into the lumen.
However, post-stent management involves
antiplatelet therapy, placing the patient at risk
for intracranial hemorrhage [45].
(c)
tive treatment of the stenosis may be the best
course of action in this situation.
-
-
506
C. Kim and M. E. Jensen
Fig. 45.2 (a) 68-year-old man with cardiomyopathy admitted for eval-
uation of ventricular tachycardia, who had a witnessed onset of leftsided weakness and facial droop with an NIHSS score of 24. Non-contrast
CT scan shows a hyperdense thrombus involving the distal internal
carotid artery (ICA) (black arrow), the middle cerebral artery (MCA)
trunk (open black arrow), and the anterior cerebral artery (ACA) trunk
(open white arrow). The normal density of the left MCA is seen on the
right (white arrowhead). The patient was started on IV rt-PA and taken
directly to the angiosuite for thrombectomy. AP (b) and lateral (c) cerebral angiogram views of the right ICA shows truncation of the ICA
(black arrows) by an intraluminal lling defect just distal to the anterior
choroidal artery (open arrows) with no lling of the MCA or ACA. (d, e)
Images from a uoroscopic loop shows positioning of the large-bore
intermediate catheter at the face of the thrombus. The microcatheter (d,
white arrow) was advanced over the microguidewire (d, black arrow) in
the middle cerebral artery. The tip of the large-bore intermediate catheter
is located in the cavernous segment of the ICA (d, open arrow). With the
microcatheter pinned, the intermediate catheter is advanced over it until
the tip is positioned at the face of the thrombus (e, open arrow). The
microcatheter and microguidewire are removed, and suction is applied
to the intermediate catheter while it is slowly withdrawn into the guiding
catheter located in the cervical ICA (not shown). AP (f) and lateral (g)
cerebral angiogram views of the right ICA after two suction thrombectomy passes shows TICI 2b restoration of ow to the ICA, MCA, and
ACA trunks. The ACA branches ll completely, and there is crossow to
the left ACA via the anterior communicating artery (black arrow). There
is delayed ow in the left MCA branches due to a small amount of residual clot in the MCA trifurcation (open arrow). The patient’s NIHSS
score was 0 at 24h, and he was discharged home after a cardiac evaluation showed no intracardiac thrombus
Fig. 45.3 A 53-year-old man presented with right-sided numbness and
dysarthria (NIHSS = 3). (a) CTA shows normal left MCA trunk and
branches; specically, the MCA posterior division is patent (arrows). He
was treated with IV rt-PA.Workup for a cryptogenic embolic source was
negative, and he was discharged on aspirin with NIHSS of 0. He presented
5months later with right hemiparesis, expressive aphasia, and confusion
(NIHSS=10). (b) CTA shows truncation of the posterior division (white
arrow). However, the distal MCA branches are noted to ll robustly compared to the right MCA territory, and to the previous CTA, indicating the
presence of good collaterals. Second (c) and third phases (d) from the multiphase CTA.Overall the multiphase study shows good collaterals (c) with
delayed transit time through the MCA middle division. (e) After receiving
IV rt-PA, a DWI MRI was done showing preserved middle division cortex
with only small areas of restricted diffusion. Thrombectomy was performed
to prevent further infarction of this “at-risk” tissue. (f) Lateral angiographic
view of the left ICA shows occlusion of the middle division (arrow) with
ACA collaterals retrograde lling the ischemic territory (arrowheads). (g)
The intermediate catheter was advanced into the MCA trunk, and a stentriever device was deployed. The open arrows point to the device’s markers.
Partial lling of the vessel is seen through the stentriever. (h) After retrieval
of the thrombus, the middle division is patent (white arrow) with normal
antegrade ow to its branches (arrowheads). Discharge NIHSS was 0
508
C. Kim and M. E. Jensen
Fig. 45.4 A 70-year-old man presented to an outside hospital with
right hemiplegia and aphasia. (a) Neck CTA shows occlusion of the left
ICA at its origin (white arrow). (b) Head CTA shows thrombus in the
supraclinoid ICA (black arrow) and (c) irregular thrombus in the MCA
trunk (arrow) with no lling of the MCA trifurcation branches. The
patient received IV rt-PA and was transported to our Comprehensive
45 Stroke
509
Fig. 45.4 (continued) Stroke Center for potential thrombectomy. Upon
arrival, the patient remained aphasic and hemiplegic (NIHSS=27). (d)
Lateral angiogram shows a near-complete occlusion of the left ICA at
the carotid bifurcation (arrow). (e) Angioplasty with a 4-mm balloon
(open arrows) was performed to allow passage of the thrombectomy
system. (f) Marked improvement in the ICA lumen size after angioplasty is seen (white arrow). (g) AP angiogram of the left ICA shows
complete occlusion of the left MCA trunk just distal to its origin
(arrow). The supraclinoid ICA clot noted on the head CTA is not seen
Table 45.5 Modied thrombolysis in cerebral infarction (mTICI) scale
Grade Angiographic appearance
0 No perfusion
1 Antegrade perfusion past the occlusion but limited distal
branch lling
2 2a: antegrade perfusion, <50% of expected vascular territory
2b: antegrade perfusion, ≥50% of expected vascular territory
3 Antegrade complete reperfusion
Key Point
ADAPT technique = a direct aspiration rst pass
technique utilizing a large catheter for direct aspiration
of a thrombus.
Key Point
Stent retriever thrombectomy (stentriever) utilizes a
self-expanding stent in the area of vessel occlusion
which is unsheathed by a microcatheter. It works by
integrating the thrombotic material into the stent struts
during expansion restoring partial reperfusion. The
stent is then removed along with the thrombus.
and most likely embolized distally into the MCA trunk. (h) An unsubtracted AP view shows the tip of the intermediate catheter in the supraclinoid ICA (white arrow) and the stentriever (open arrows) spanning
the clot in the MCA trunk. After retrieval of the thrombus, AP (i), and
lateral (j), angiographic views of the left ICA show complete lling of
the MCA territory. Diminished caliber of the MCA trunk (arrows) is
due to irritation of the vessel wall musculature from removal of the
stentriever, resulting in transient vasospasm. The patient returned
3weeks later for stenting of the left cervical ICA stenosis
Complications
Intraparenchymal hemorrhage associated with ischemic
stroke is a known risk and may take the form of hemorrhagic
transformation or intraparenchymal hematoma. The risk is
increased with the administration of IV rt-PA.In the major
randomized embolectomy trials, the endovascularly treated
group did not have an increased incidence of symptomatic
intraparenchymal hematoma when compared to the control
group that received best medical therapy, including IV rt-PA
[26–30]. However, the MR CLEAN trial showed a signicant (5.6%) incidence of new ischemic stroke in a different
vascular territory compared to the control group (0.4%) [26].
This complication is most likely due to fragmentation and
embolization of the thrombus during retrieval. Mortality was
equal between study groups in MR CLEAN and signicantly
decreased in the interventional group in ESCAPE and
SWIFT-PRIME. The most common technical complication
was wire perforation, with the highest occurring in the
EXTEND-IA trial (2.9%).
Complications associated with angiography include
bleeding, hematoma formation, vascular injury or occlusion at the puncture site, and contrast-induced nephropathy.
Cerebral angiography complications include dissection,
pseudoaneurysm formation, and vessel occlusion of the
510
C. Kim and M. E. Jensen
cervicocerebral arteries. Intracranial vasospasm may occur,
particularly with the use of stentrievers (Fig.45.4i). Severe
spasm can be treated with intra-arterial injection of verapamil. Perforation or transection of an intracranial vessel is
the most feared complication. Manipulation of the microwire or microcatheter past the clot is fraught with danger as
the maneuvers are done blindly based on the operator’s
expectation of vessel location. Perforation by the
microcatheter or microwire may cause subarachnoid or
intraparenchymal hemorrhage. An abrupt alteration in the
patient’s vital signs with hypertension and bradycardia
(Cushing’s reex) is indicative of increased intracranial
pressure. Intraparenchymal hemorrhage may be noted by
areas of contrast layering in an extravascular area.
Equipment failure is a potential problem, and the operator
should be familiar with device tolerances.
Key Point
Cushing’s reex = hypertension, bradycardia, and
changes in respiration which indicate increased intracranial pressure. These ndings are concerning for
subarachnoid hemorrhage when they occur abruptly
during the procedure.
Post-procedure Management
Following endovascular treatment, patients are admitted to
the intensive care unit for close neurological observation and
further routine post-stroke care. Groin and distal pulse
checks are performed at the same time as the vital signs and
neurological examinations. General anesthesia patients are
extubated as soon as possible. A routine MRI is done within
24h to determine infarct size. Emergent head CT is obtained
for any signicant neurological change. All patients have a
swallow test before initiating a diet. The complete list of recommendations can be found in the AHA guidelines [9, 12].
Publication of specic post-thrombectomy guidelines by the
Society of NeuroInterventional Surgery is forthcoming [46].
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