Acute Ischemic Stroke Reperfusion Selection

Use noncontrast head CT first to exclude intracranial hemorrhage and assess early ischemic change. For potential thrombectomy candidates, add CTA of the head and neck immediately to identify proximal large-vessel occlusion (LVO); in the 0- to 6-hour window, noncontrast CT plus CTA is the core imaging strategy. jaccjaccHyperacute Management of Ischemic Strokes: JACC Focus Seminar

Calculate Alberta Stroke Program Early CT Score (ASPECTS) on noncontrast CT for anterior-circulation stroke. In the early window, an ASPECTS of at least 6 is an example of absence of extensive infarct core supporting thrombectomy selection; low ASPECTS should trigger stroke-neurology and neurointerventional discussion rather than automatic procedural exclusion based only on symptom severity. BMJBMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional Surgery

Do not use an upper NIHSS threshold to deny thrombectomy when CTA shows LVO. ESO–ESMINT recommends thrombectomy plus best medical management for high-severity LVO stroke and specifies no upper NIHSS limit for treatment decisions. BMJBMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional Surgery

For anterior-circulation LVO presenting within 6 hours, perform mechanical thrombectomy (MT) plus best medical management rather than medical management alone when imaging does not show extensive infarct core. Guideline examples of favorable baseline imaging are ASPECTS at least 6 on noncontrast CT or infarct-core volume no greater than 70 mL. BMJBMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional Surgery

Treat LVO as a procedural emergency after CTA confirmation. Modern thrombectomy trials demonstrated major functional benefit, with numbers needed to treat of 3 for any improvement in functional outcome and 5 for functional independence in the pivotal-trial evidence base; delays in endovascular treatment worsen outcome, so imaging review, interfacility transfer, and angiography-suite activation should occur concurrently. BMJ+1BMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic StrokeJAMATime to Treatment With Endovascular Thrombectomy and Outcomes ...

Age alone should not exclude treatment. Guidance supports thrombectomy in older adults, including those older than 80 years, when otherwise eligible; selection should instead emphasize LVO anatomy, established infarct burden, time from last known well, and applicable trial-derived imaging criteria. BMJ+1BMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic StrokeBMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional Surgery

For LVO from 6 to 24 hours after last known well, thrombectomy is recommended when the patient fulfills DAWN or DEFUSE-3 inclusion criteria. This applies to high-severity LVO stroke and extends to patients older than 80 years when the applicable imaging-selection criteria are met. BMJ+1BMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic StrokeBMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional Surgery

Use CT perfusion or MR diffusion/perfusion to estimate established core and hypoperfused but potentially salvageable tissue. Perfusion-based paradigms move selection from clock time toward tissue status, but very early perfusion acquisition can overestimate ischemic core because infarct evolution and reperfusion may occur after imaging. AHA JournalsAHA JournalsReview of Perfusion Imaging in Acute Ischemic Stroke

Interpret automated or protocol-derived estimates in the clinical and anatomic context. A mismatch profile supports reperfusion only when an occlusion target is present and the patient meets a validated trial-selection framework; perfusion imaging should refine late-window selection, not replace CTA confirmation of LVO. BMJ+2BMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional SurgeryjaccHyperacute Management of Ischemic Strokes: JACC Focus SeminarAHA JournalsReview of Perfusion Imaging in Acute Ischemic Stroke

For an eligible patient with acute ischemic stroke and LVO who is proceeding to MT, administer intravenous thrombolysis as part of best medical management whenever indicated; do not defer the thrombectomy pathway to observe whether systemic thrombolysis recanalizes the vessel. BMJ+2BMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic StrokeBMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional SurgeryAHA JournalsSuccessful Reperfusion With Intravenous Thrombolysis Preceding Mechanical Thrombectomy in Large-Vessel Occlusions

The reason to preserve bridging therapy is that some patients achieve successful reperfusion before the endovascular procedure, potentially averting MT, whereas many proximal LVOs do not achieve complete recanalization with intravenous thrombolysis alone. Procedural activation and transfer must therefore continue during thrombolytic administration. BMJ+1BMJ30 years of thrombolysis for ischaemic stroke: expanded agents ...AHA JournalsSuccessful Reperfusion With Intravenous Thrombolysis Preceding Mechanical Thrombectomy in Large-Vessel Occlusions

Maintain blood pressure below 185/110 mm Hg before intravenous thrombolysis. During reperfusion therapy, avoid blood pressure above 180/105 mm Hg through early, modest blood-pressure control. Oxford Academic+1Oxford Academic2025 update to European Stroke Organisation (ESO) guideline on ...Oxford AcademicEuropean Stroke Organisation (ESO) guidelines on blood pressure ...

The strongest recommendation applies to LVO-related anterior-circulation stroke within 6 hours without extensive infarct core, and to 6- to 24-hour LVO meeting DAWN or DEFUSE-3 criteria. A patient outside these profiles should undergo individualized multidisciplinary assessment rather than being labeled ineligible because of a single factor such as age or NIHSS. BMJ+1BMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic StrokeBMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional Surgery

Medium- or distal-vessel occlusion should not be managed as though it has the same established evidence base as proximal LVO. Recent randomized trials of endovascular treatment for medium-vessel occlusion have produced varying results, making vessel-level anatomy and local neurointerventional expertise especially important to procedural decisions. NEJMNEJMEndovascular Treatment of Medium-Vessel-Occlusion Strokes

When an LVO is identified at a nonthrombectomy hospital, arrange rapid endovascular-capable transfer while continuing indicated medical reperfusion therapy. The expected benefit of MT is time-sensitive, and treatment delay should be treated as a systems failure risk rather than a reason to defer referral. JAMA+1JAMATime to Treatment With Endovascular Thrombectomy and Outcomes ...JAMAHealthy Life-Year Costs of Treatment Speed From Arrival to ...