Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery.
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.
Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
Ryan A
RA
McTaggart
Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Sameer A
SA
Ansari
Department of Neurosurgery, University of Calgary, Calgary, Alberta, Canada.
Mayank
M
Goyal
Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA.
Todd A
TA
Abruzzo
Department of Neurointerventional Surgery, Christiana Care Health Systems, Newark, Delaware, USA.
Barb
B
Albani
Department of Neurosurgery, Semmes-Murphey Clinic, Memphis, Tennessee, USA.
Adam J
AJ
Arthur
Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.
Michael J
MJ
Alexander
Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
Felipe C
FC
Albuquerque
Department of Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA.
Blaise
B
Baxter
Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA.
Ketan R
KR
Bulsara
Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA.
Michael
M
Chen
Department of Interventional Neuroradiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.
Josser E Delgado
JE
Almandoz
Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA.
Justin F
JF
Fraser
Radiology Imaging Associates, Interventional Neuroradiology, Englewood, Colorado, USA.
Donald
D
Frei
Department of Neurological Surgery, Rutgers University-New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.
Chirag D
CD
Gandhi
Department of Radiology, Forsyth Medical Center, Winston Salem, North Carolina, USA.
Don V
DV
Heck
Department of Radiology, UCSF, San Francisco, California, USA.
Steven W
SW
Hetts
Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA.
M Shazam
MS
Hussain
Department of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Michael
M
Kelly
Department of Interventional Neuroradiology, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA.
Richard
R
Klucznik
Department of Radiology, The University of Chicago, Chicago, Illinois, USA.
Seon-Kyu
SK
Lee
Department of Neurointerventional Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.
Thabele
T
Leslie-Mawzi
Department of Neurointerventional Surgery, Columbia Presbyterian Hospital, New York, New York, USA.
Philip M
PM
Meyers
Department of Neurological Surgery, Rutgers University-New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.
Charles J
CJ
Prestigiacomo
Department of Neuroradiology, UT Southwestern, Dallas, Texas, USA.
G Lee
GL
Pride
Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA.
Athos
A
Patsalides
Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
Robert M
RM
Starke
Department of Radiology, Banner Good Samaritan Medical Center, Phoenix, Arizona, USA.
Peter
P
Sunenshine
Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA.
Peter A
PA
Rasmussen
Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
Mahesh V
MV
Jayaraman
D002561:Cerebrovascular Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D019468:Disease Management; D017128:Embolectomy / Q000592:standards; D057510:Endovascular Procedures / Q000379:methods / Q000592:standards; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006760:Hospitalization; D006801:Humans; D019635:Neurosurgical Procedures / Q000379:methods / Q000592:standards*; D018579:Patient Selection; D017410:Practice Guidelines as Topic / Q000592:standards*; D015424:Reperfusion / Q000379:methods / Q000592:standards; D058028:Research Report / Q000592:standards*; D012955:Societies, Medical / Q000592:standards*; D020521:Stroke / Q000175:diagnosis / Q000517:prevention & control / Q000601:surgery; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014481:United States / Q000453:epidemiology
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
Stroke