Initial hospital management of patients with emergent large vessel occlusion (ELVO): Report of the standards and guidelines committee of the Society of NeuroInterventional Surgery

Ryan A. McTaggart, Sameer A. Ansari, Mayank Goyal, Todd A. Abruzzo, Barb Albani, Adam J. Arthur, Michael J. Alexander, Felipe C. Albuquerque, Blaise Baxter, Ketan R. Bulsara, Michael Chen, Josser E.Delgado Almandoz, Justin F. Fraser, Donald Frei, Chirag D. Gandhi, Don V. Heck, Steven W. Hetts, M. Shazam Hussain, Michael Kelly, Richard KlucznikSeon Kyu Lee, Thabele Leslie-Mawzi, Philip M. Meyers, Charles J. Prestigiacomo, G. Lee Pride, Athos Patsalides, Robert M. Starke, Peter Sunenshine, Peter A. Rasmussen, Mahesh V. Jayaraman

Research output: Contribution to journalArticle

54 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)316-323
Number of pages8
JournalJournal of neurointerventional surgery
Volume9
Issue number3
DOIs
StatePublished - Mar 2017

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Guidelines
Stroke
Embolectomy
Therapeutics
Endovascular Procedures
Perfusion Imaging
Workflow
Triage
Fibrinolysis
Tissue Plasminogen Activator
General Anesthesia
Nervous System
Reperfusion
Perfusion
Medicine
Morbidity
Mortality
Brain

All Science Journal Classification (ASJC) codes

  • Surgery
  • Clinical Neurology

Cite this

Initial hospital management of patients with emergent large vessel occlusion (ELVO) : Report of the standards and guidelines committee of the Society of NeuroInterventional Surgery. / McTaggart, Ryan A.; Ansari, Sameer A.; Goyal, Mayank; Abruzzo, Todd A.; Albani, Barb; Arthur, Adam J.; Alexander, Michael J.; Albuquerque, Felipe C.; Baxter, Blaise; Bulsara, Ketan R.; Chen, Michael; Almandoz, Josser E.Delgado; Fraser, Justin F.; Frei, Donald; Gandhi, Chirag D.; Heck, Don V.; Hetts, Steven W.; Hussain, M. Shazam; Kelly, Michael; Klucznik, Richard; Lee, Seon Kyu; Leslie-Mawzi, Thabele; Meyers, Philip M.; Prestigiacomo, Charles J.; Pride, G. Lee; Patsalides, Athos; Starke, Robert M.; Sunenshine, Peter; Rasmussen, Peter A.; Jayaraman, Mahesh V.

In: Journal of neurointerventional surgery, Vol. 9, No. 3, 03.2017, p. 316-323.

Research output: Contribution to journalArticle

McTaggart, RA, Ansari, SA, Goyal, M, Abruzzo, TA, Albani, B, Arthur, AJ, Alexander, MJ, Albuquerque, FC, Baxter, B, Bulsara, KR, Chen, M, Almandoz, JED, Fraser, JF, Frei, D, Gandhi, CD, Heck, DV, Hetts, SW, Hussain, MS, Kelly, M, Klucznik, R, Lee, SK, Leslie-Mawzi, T, Meyers, PM, Prestigiacomo, CJ, Pride, GL, Patsalides, A, Starke, RM, Sunenshine, P, Rasmussen, PA & Jayaraman, MV 2017, 'Initial hospital management of patients with emergent large vessel occlusion (ELVO): Report of the standards and guidelines committee of the Society of NeuroInterventional Surgery', Journal of neurointerventional surgery, vol. 9, no. 3, pp. 316-323. https://doi.org/10.1136/neurintsurg-2015-011984
McTaggart, Ryan A. ; Ansari, Sameer A. ; Goyal, Mayank ; Abruzzo, Todd A. ; Albani, Barb ; Arthur, Adam J. ; Alexander, Michael J. ; Albuquerque, Felipe C. ; Baxter, Blaise ; Bulsara, Ketan R. ; Chen, Michael ; Almandoz, Josser E.Delgado ; Fraser, Justin F. ; Frei, Donald ; Gandhi, Chirag D. ; Heck, Don V. ; Hetts, Steven W. ; Hussain, M. Shazam ; Kelly, Michael ; Klucznik, Richard ; Lee, Seon Kyu ; Leslie-Mawzi, Thabele ; Meyers, Philip M. ; Prestigiacomo, Charles J. ; Pride, G. Lee ; Patsalides, Athos ; Starke, Robert M. ; Sunenshine, Peter ; Rasmussen, Peter A. ; Jayaraman, Mahesh V. / Initial hospital management of patients with emergent large vessel occlusion (ELVO) : Report of the standards and guidelines committee of the Society of NeuroInterventional Surgery. In: Journal of neurointerventional surgery. 2017 ; Vol. 9, No. 3. pp. 316-323.
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title = "Initial hospital management of patients with emergent large vessel occlusion (ELVO): Report of the standards and guidelines committee of the Society of NeuroInterventional Surgery",
abstract = "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.",
author = "McTaggart, {Ryan A.} and Ansari, {Sameer A.} and Mayank Goyal and Abruzzo, {Todd A.} and Barb Albani and Arthur, {Adam J.} and Alexander, {Michael J.} and Albuquerque, {Felipe C.} and Blaise Baxter and Bulsara, {Ketan R.} and Michael Chen and Almandoz, {Josser E.Delgado} and Fraser, {Justin F.} and Donald Frei and Gandhi, {Chirag D.} and Heck, {Don V.} and Hetts, {Steven W.} and Hussain, {M. Shazam} and Michael Kelly and Richard Klucznik and Lee, {Seon Kyu} and Thabele Leslie-Mawzi and Meyers, {Philip M.} and Prestigiacomo, {Charles J.} and Pride, {G. Lee} and Athos Patsalides and Starke, {Robert M.} and Peter Sunenshine and Rasmussen, {Peter A.} and Jayaraman, {Mahesh V.}",
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T1 - Initial hospital management of patients with emergent large vessel occlusion (ELVO)

T2 - Report of the standards and guidelines committee of the Society of NeuroInterventional Surgery

AU - McTaggart, Ryan A.

AU - Ansari, Sameer A.

AU - Goyal, Mayank

AU - Abruzzo, Todd A.

AU - Albani, Barb

AU - Arthur, Adam J.

AU - Alexander, Michael J.

AU - Albuquerque, Felipe C.

AU - Baxter, Blaise

AU - Bulsara, Ketan R.

AU - Chen, Michael

AU - Almandoz, Josser E.Delgado

AU - Fraser, Justin F.

AU - Frei, Donald

AU - Gandhi, Chirag D.

AU - Heck, Don V.

AU - Hetts, Steven W.

AU - Hussain, M. Shazam

AU - Kelly, Michael

AU - Klucznik, Richard

AU - Lee, Seon Kyu

AU - Leslie-Mawzi, Thabele

AU - Meyers, Philip M.

AU - Prestigiacomo, Charles J.

AU - Pride, G. Lee

AU - Patsalides, Athos

AU - Starke, Robert M.

AU - Sunenshine, Peter

AU - Rasmussen, Peter A.

AU - Jayaraman, Mahesh V.

PY - 2017/3

Y1 - 2017/3

N2 - 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.

AB - 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.

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