treatment of ischemic stroke. N Engl J Med 2015; 372:1019. 25. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t- PA alone in stroke. N Engl J Med 2015; 372:2285. 26. Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372:1009. 27. Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372:2296. 28. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387:1723. 29. Marmagkiolis K, Hakeem A, Cilingiroglu M, et al. Safety and Efficacy of Stent Retrievers for the Management of Acute Ischemic Stroke: Comprehensive Review and Meta-Analysis. JACC Cardiovasc Interv 2015; 8:1758. 30. Consensus statement on mechanical thrombectomy in acute ischemic stroke ESO-Karolins ka Stroke Update 2014 in collaboration with ESMINT and ESNR. http://2014.strokeupdate.or g/consensus-statement-mechanical-thrombectomy-acute-ischemic-stroke (Accessed on July 13, 2015). 31. Fransen PS, Berkhemer OA, Lingsma HF, et al. Time to Reperfusion and Treatment Effect for Acute Ischemic Stroke: A Randomized Clinical Trial. JAMA Neurol 2016; 73:190. 32. Touma L, Filion KB, Sterling LH, et al. Stent Retrievers for the Treatment of Acute Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Clinical Trials. JAMA Neurol 2016; 73:275. 33. Tsivgoulis G, Katsanos AH, Mavridis D, et al. Mechanical Thrombectomy Improves Functional Outcomes Independent of Pretreatment With Intravenous Thrombolysis. Stroke 2016; https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 23/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate 47:1661. 34. Saver JL, Goyal M, van der Lugt A, et al. Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis. JAMA 2016; 316:1279. 35. D valos A, Cobo E, Molina CA, et al. Safety and efficacy of thrombectomy in acute ischaemic stroke (REVASCAT): 1-year follow-up of a randomised open-label trial. Lancet Neurol 2017; 16:369. 36. Mocco J, Zaidat OO, von Kummer R, et al. Aspiration Thrombectomy After Intravenous Alteplase Versus Intravenous Alteplase Alone. Stroke 2016; 47:2331. 37. Muir KW, Ford GA, Messow CM, et al. Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial. J Neurol Neurosurg Psychiatry 2017; 88:38. 38. Khoury NN, Darsaut TE, Ghostine J, et al. Endovascular thrombectomy and medical therapy versus medical therapy alone in acute stroke: A randomized care trial. J Neuroradiol 2017; 44:198. 39. Martins SO, Mont'Alverne F, Rebello LC, et al. Thrombectomy for Stroke in the Public Health Care System of Brazil. N Engl J Med 2020; 382:2316. 40. Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013; 368:904. 41. Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013; 368:893. 42. Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013; 368:914. 43. Hacke W. Interventional thrombectomy for major stroke a step in the right direction. N Engl J Med 2015; 372:76. 44. Kobeissi H, Ghozy S, Adusumilli G, et al. CT Perfusion vs Noncontrast CT for Late Window Stroke Thrombectomy: A Systematic Review and Meta-analysis. Neurology 2023; 100:e2304. 45. Nguyen TN, Abdalkader M, Nagel S, et al. Noncontrast Computed Tomography vs Computed Tomography Perfusion or Magnetic Resonance Imaging Selection in Late Presentation of Stroke With Large-Vessel Occlusion. JAMA Neurol 2022; 79:22. 46. Miao J, Sang H, Li F, et al. Effect of Imaging Selection Paradigms on Endovascular Thrombectomy Outcomes in Patients With Acute Ischemic Stroke. Stroke 2023; 54:1569. 47. Baron JC. Selection of Patients for Thrombectomy in the Extended Time Window. JAMA Neurol 2021; 78:1051. https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 24/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate 48. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med 2018; 378:11. 49. Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med 2018; 378:708. 50. Jovin TG, Nogueira RG, Lansberg MG, et al. Thrombectomy for anterior circulation stroke beyond 6 h from time last known well (AURORA): a systematic review and individual patient data meta-analysis. Lancet 2022; 399:249. 51. Albers GW, Lansberg MG, Brown S, et al. Assessment of Optimal Patient Selection for Endovascular Thrombectomy Beyond 6 Hours After Symptom Onset: A Pooled Analysis of the AURORA Database. JAMA Neurol 2021; 78:1064. 52. Dittrich TD, Sporns PB, Kriemler LF, et al. Mechanical Thrombectomy Versus Best Medical Treatment in the Late Time Window in Non-DEFUSE-Non-DAWN Patients: A Multicenter Cohort Study. Stroke 2023; 54:722. 53. Yoshimura S, Sakai N, Yamagami H, et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med 2022; 386:1303. 54. Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes. N Engl J Med 2023; 388:1259. 55. Huo X, Ma G, Tong X, et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct. N Engl J Med 2023; 388:1272. 56. Fayad P. Improved Prospects for Thrombectomy in Large Ischemic Stroke. N Engl J Med 2023; 388:1326. 57. Li Q, Abdalkader M, Siegler JE, et al. Mechanical Thrombectomy for Large Ischemic Stroke: A Systematic Review and Meta-Analysis. Neurology 2023. 58. Olthuis SGH, Pirson FAV, Pinckaers FME, et al. Endovascular treatment versus no endovascular treatment after 6-24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded- endpoint, randomised, controlled, phase 3 trial. Lancet 2023; 401:1371. 59. Berkhemer OA, Jansen IG, Beumer D, et al. Collateral Status on Baseline Computed Tomographic Angiography and Intra-Arterial Treatment Effect in Patients With Proximal Anterior Circulation Stroke. Stroke 2016; 47:768. 60. Menon BK, Qazi E, Nambiar V, et al. Differential Effect of Baseline Computed Tomographic Angiography Collaterals on Clinical Outcome in Patients Enrolled in the Interventional Management of Stroke III Trial. Stroke 2015; 46:1239. https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 25/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate 61. Liu X, Dai Q, Ye R, et al. Endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST): an open-label, randomised controlled trial. Lancet Neurol 2020; 19:115. 62. Meyer L, Stracke CP, Jungi N, et al. Thrombectomy for Primary Distal Posterior Cerebral Artery Occlusion Stroke: The TOPMOST Study. JAMA Neurol 2021; 78:434. 63. Langezaal LCM, van der Hoeven EJRJ, Mont'Alverne FJA, et al. Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion. N Engl J Med 2021; 384:1910. 64. Li F, Sang H, Song J, et al. One-Year Outcome After Endovascular Treatment for Acute Basilar Artery Occlusion. Stroke 2022; 53:e9. 65. Sabben C, Charbonneau F, Delvoye F, et al. Endovascular Therapy or Medical Management Alone for Isolated Posterior Cerebral Artery Occlusion: A Multicenter Study. Stroke 2023; 54:928. 66. Baig AA, Monteiro A, Waqas M, et al. Acute isolated posterior cerebral artery stroke treated with mechanical thrombectomy: A single-center experience and review of the literature. Interv Neuroradiol 2023; 29:10. 67. Alemseged F, Nguyen TN, Alverne FM, et al. Endovascular Therapy for Basilar Artery Occlusion. Stroke 2023; 54:1127. 68. Tao C, Nogueira RG, Zhu Y, et al. Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion. N Engl J Med 2022; 387:1361. 69. Jovin TG, Li C, Wu L, et al. Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar- Artery Occlusion. N Engl J Med 2022; 387:1373. 70. Wintermark M, Albers GW, Broderick JP, et al. Acute Stroke Imaging Research Roadmap II. Stroke 2013; 44:2628. 71. Menon BK, Goyal M. Thrombus aspiration or retrieval in acute ischaemic stroke. Lancet 2019; 393:962. 72. Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 2005; 36:1432. 73. Brinjikji W, Rabinstein AA, Kallmes DF, Cloft HJ. Patient outcomes with endovascular embolectomy therapy for acute ischemic stroke: a study of the national inpatient sample: 2006 to 2008. Stroke 2011; 42:1648. 74. Broderick JP, Schroth G. What the SWIFT and TREVO II trials tell us about the role of endovascular therapy for acute stroke. Stroke 2013; 44:1761. 75. Saver JL, Jahan R, Levy EI, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 26/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate trial. Lancet 2012; 380:1241. 76. Nogueira RG, Lutsep HL, Gupta R, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012; 380:1231. 77. Gupta R, Saver JL, Levy E, et al. New Class of Radially Adjustable Stentrievers for Acute Ischemic Stroke: Primary Results of the Multicenter TIGER Trial. Stroke 2021; 52:1534. 78. Lapergue B, Blanc R, Gory B, et al. Effect of Endovascular Contact Aspiration vs Stent Retriever on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion: The ASTER Randomized Clinical Trial. JAMA 2017; 318:443. 79. Turk AS 3rd, Siddiqui A, Fifi JT, et al. Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial. Lancet 2019; 393:998. 80. Bernsen MLE, Goldhoorn RB, Lingsma HF, et al. Importance of Occlusion Site for Thrombectomy Technique in Stroke: Comparison Between Aspiration and Stent Retriever. Stroke 2021; 52:80. 81. Lapergue B, Blanc R, Costalat V, et al. Effect of Thrombectomy With Combined Contact Aspiration and Stent Retriever vs Stent Retriever Alone on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion: The ASTER2 Randomized Clinical Trial. JAMA 2021; 326:1158. 82. van der Steen W, van de Graaf RA, Chalos V, et al. Safety and efficacy of aspirin, unfractionated heparin, both, or neither during endovascular stroke treatment (MR CLEAN- MED): an open-label, multicentre, randomised controlled trial. Lancet 2022; 399:1059. 83. Samuels N, van de Graaf RA, Mulder MJHL, et al. Admission systolic blood pressure and effect of endovascular treatment in patients with ischaemic stroke: an individual patient data meta-analysis. Lancet Neurol 2023; 22:312. 84. Biller J, Bulwa Z, Gomez CR, Morales-Vidal S. Stroke snapshot: Blood pressure management after acute ischemic stroke. Pract Neurol (Fort Washington, Pa.) 2019; March/April:13. 85. Ma er B, Fahed R, Khoury N, et al. Association of Blood Pressure During Thrombectomy for Acute Ischemic Stroke With Functional Outcome: A Systematic Review. Stroke 2019; 50:2805. 86. Mazighi M, Richard S, Lapergue B, et al. Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke (BP-TARGET): a multicentre, open-label, randomised controlled trial. Lancet Neurol 2021; 20:265. 87. Mistry E, Hart K, Davis L, et al. Blood pressure after endovascular stroke treatment (BEST)-II: A randomized clinical trial. Presented at: 2023 International Stroke Conference; February 8-1 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 27/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate 0; Dallas, TX. LB18. 88. Morris NA, Jindal G, Chaturvedi S. Intensive Blood Pressure Control After Mechanical Thrombectomy for Acute Ischemic Stroke. Stroke 2023; 54:1457. 89. Anadani M, Arthur AS, Tsivgoulis G, et al. Blood Pressure Goals and Clinical Outcomes after Successful Endovascular Therapy: A Multicenter Study. Ann Neurol 2020; 87:830. 90. Yang P, Song L, Zhang Y, et al. Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet 2022; 400:1585. 91. Mistry EA, Nguyen TN. Blood pressure goals after mechanical thrombectomy: a moving target. Lancet 2022; 400:1558. 92. Chen JH, Hong CT, Chung CC, et al. Safety and efficacy of endovascular thrombectomy in acute ischemic stroke treated with anticoagulants: a systematic review and meta-analysis. Thromb J 2022; 20:35. 93. Mac Grory B, Holmes DN, Matsouaka RA, et al. Recent Vitamin K Antagonist Use and Intracranial Hemorrhage After Endovascular Thrombectomy for Acute Ischemic Stroke. JAMA 2023; 329:2038. 94. Jadhav AP, Zaidat OO, Liebeskind DS, et al. Emergent Management of Tandem Lesions in Acute Ischemic Stroke. Stroke 2019; 50:428. 95. Jacquin G, Poppe AY, Labrie M, et al. Lack of Consensus Among Stroke Experts on the Optimal Management of Patients With Acute Tandem Occlusion. Stroke 2019; 50:1254. 96. Poppe AY, Jacquin G, Roy D, et al. Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions. AJNR Am J Neuroradiol 2020; 41:1142. 97. Dufort G, Chen BY, Jacquin G, et al. Acute carotid stenting in patients undergoing thrombectomy: a systematic review and meta-analysis. J Neurointerv Surg 2021; 13:141. 98. Anadani M, Marnat G, Consoli A, et al. Endovascular Therapy of Anterior Circulation Tandem Occlusions: Pooled Analysis From the TITAN and ETIS Registries. Stroke 2021; 52:3097. 99. Abdalla RN, Cantrell DR, Shaibani A, et al. Refractory Stroke Thrombectomy: Prevalence, Etiology, and Adjunctive Treatment in a North American Cohort. AJNR Am J Neuroradiol 2021; 42:1258. 100. Flottmann F, Leischner H, Broocks G, et al. Recanalization Rate per Retrieval Attempt in Mechanical Thrombectomy for Acute Ischemic Stroke. Stroke 2018; 49:2523. 101. Tsang COA, Cheung IHW, Lau KK, et al. Outcomes of Stent Retriever versus Aspiration-First Thrombectomy in Ischemic Stroke: A Systematic Review and Meta-Analysis. AJNR Am J https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 28/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate Neuroradiol 2018; 39:2070. 102. Marnat G, Delvoye F, Finitsis S, et al. A Multicenter Preliminary Study of Cangrelor following Thrombectomy Failure for Refractory Proximal Intracranial Occlusions. AJNR Am J Neuroradiol 2021; 42:1452. 103. Mohammaden MH, Haussen DC, Al-Bayati AR, et al. Stenting and Angioplasty in Neurothrombectomy: Matched Analysis of Rescue Intracranial Stenting Versus Failed Thrombectomy. Stroke 2022; 53:2779. 104. Maingard J, Phan K, Lamanna A, et al. Rescue Intracranial Stenting After Failed Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 132:e235. 105. Hassan AE, Ringheanu VM, Preston L, et al. 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JAMA 2022; 327:821. Topic 115663 Version 40.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 29/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate GRAPHICS Eligibility criteria for the treatment of acute ischemic stroke with intravenous thrombolysis (recombinant tissue plasminogen activator or tPA) Inclusion criteria Clinical diagnosis of ischemic stroke causing measurable neurologic deficit Onset of symptoms <4.5 hours before beginning treatment; if the exact time of stroke onset is not known, it is defined as the last time the patient was known to be normal or at neurologic baseline Age 18 years Exclusion criteria Patient history Ischemic stroke or severe head trauma in the previous three months Previous intracranial hemorrhage Intra-axial intracranial neoplasm Gastrointestinal malignancy Gastrointestinal hemorrhage in the previous 21 days Intracranial or intraspinal surgery within the prior three months Clinical Symptoms suggestive of subarachnoid hemorrhage Persistent blood pressure elevation (systolic 185 mmHg or diastolic 110 mmHg) Active internal bleeding Presentation consistent with infective endocarditis Stroke known or suspected to be associated with aortic arch dissection Acute bleeding diathesis, including but not limited to conditions defined under 'Hematologic' Hematologic 3 Platelet count <100,000/mm * Current anticoagulant use with an INR >1.7 or PT >15 seconds or aPTT >40 seconds* Therapeutic doses of low molecular weight heparin received within 24 hours (eg, to treat VTE and ACS); this exclusion does not apply to prophylactic doses (eg, to prevent VTE) Current use (ie, last dose within 48 hours in a patient with normal renal function) of a direct thrombin inhibitor or direct factor Xa inhibitor with evidence of anticoagulant effect by laboratory tests such as aPTT, INR, ECT, TT, or appropriate factor Xa activity assays Head CT https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 30/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate Evidence of hemorrhage Extensive regions of obvious hypodensity consistent with irreversible injury Warnings Only minor and isolated neurologic signs or rapidly improving symptoms Serum glucose <50 mg/dL (<2.8 mmol/L) Serious trauma in the previous 14 days Major surgery in the previous 14 days History of gastrointestinal bleeding (remote) or genitourinary bleeding Seizure at the onset of stroke with postictal neurologic impairments Pregnancy** Arterial puncture at a noncompressible site in the previous seven days Large ( 10 mm), untreated, unruptured intracranial aneurysm Untreated intracranial vascular malformation Additional warnings for treatment from 3 to 4.5 hours from symptom onset Age >80 years Oral anticoagulant use regardless of INR Severe stroke (NIHSS score >25) Combination of both previous ischemic stroke and diabetes mellitus ACS: acute coronary syndrome; aPTT: activated partial thromboplastin time; ECT: ecarin clotting time; INR: international normalized ratio; PT: prothrombin time; NIHSS: National Institutes of Health Stroke Scale; tPA: intravenous alteplase; TT: thrombin time; VTE: venous thromboembolism. Although it is desirable to know the results of these tests, thrombolytic therapy should not be delayed while results are pending unless (1) there is clinical suspicion of a bleeding abnormality or thrombocytopenia, (2) the patient is currently on or has recently received anticoagulants (eg, heparin, warfarin, a direct thrombin inhibitor, or a direct factor Xa inhibitor), or (3) use of anticoagulants is not known. Otherwise, treatment with intravenous tPA can be started before availability of coagulation test results but should be discontinued if the INR, PT, or aPTT exceed the limits stated in the table, or 3 if platelet count is <100,000 mm . With careful consideration and weighting of risk-to-benefit, patients may receive intravenous alteplase despite one or more warnings. Patients who have a persistent neurologic deficit that is potentially disabling, despite improvement of any degree, should be treated with tPA in the absence of other contraindications. Any of the following should be considered disabling deficits: Complete hemianopia: 2 on NIHSS question 3, or Severe aphasia: 2 on NIHSS question 9, or Visual or sensory extinction: 1 on NIHSS question 11, or https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 31/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate Any weakness limiting sustained effort against gravity: 2 on NIHSS question 5 or 6, or Any deficits that lead to a total NIHSS >5, or Any remaining deficit considered potentially disabling in the view of the patient and the treating practitioner using clinical judgment Patients may be treated with intravenous alteplase if glucose level is subsequently normalized. The potential risks of bleeding with alteplase from injuries related to the trauma should be weighed against the anticipated benefits of reduced stroke-related neurologic deficits. The increased risk of surgical site bleeding with alteplase should be weighed against the anticipated benefits of reduced stroke-related neurologic deficits. There is a low increased risk of new bleeding with alteplase in the setting of past gastrointestinal or genitourinary bleeding. However, alteplase administration within 21 days of gastrointestinal bleeding is not recommended. Alteplase is reasonable in patients with a seizure at stroke onset if evidence suggests that residual impairments are secondary to acute ischemic stroke and not to a postictal phenomenon. * Alteplase can be given in pregnancy when the anticipated benefits of treating moderate or severe stroke outweigh the anticipated increased risks of uterine bleeding. The safety and efficacy of administering alteplase is uncertain for these relative exclusions. Although these were exclusions in the trial showing benefit in the 3 to 4.5 hour window, intravenous alteplase appears to be safe and may be beneficial for patients with these criteria, including patients taking oral anticoagulants with an INR <1.7. Adapted from: 1. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359:1317. 2. Del Zoppo GJ, Saver JL, Jauch EC, et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator. A science advisory from the American Heart Association/American Stroke Association. Stroke 2009; 40:2945. 3. Re-examining Acute Eligibility for Thrombolysis (TREAT) Task Force:, Levine SR, Khatri P, et al. Review, historical context, and clari cations of the NINDS rt-PA stroke trials exclusion criteria: Part 1: rapidly improving stroke symptoms. Stroke 2013; 44:2500. 4. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scienti c rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2016; 47:581. 5. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344. Graphic 71462 Version 26.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 32/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate National Institutes of Health Stroke Scale (NIHSS) Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (ie, repeated requests to patient to make a special effort). Instructions Scale definition Score 1a. Level of consciousness: The 0 = Alert; keenly responsive. investigator must choose a response if a full 1 = Not alert; but arousable by minor evaluation is prevented by such obstacles as an endotracheal tube, language barrier, stimulation to obey, answer, or respond. 2 = Not alert; requires repeated stimulation orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement to attend, or is obtunded and requires strong or painful stimulation to make _____ (other than reflexive posturing) in response to noxious stimulation. movements (not stereotyped). 3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, and areflexic. 1b. Level of consciousness questions: The 0 = Answers both questions correctly. patient is asked the month and his/her age. The answer must be correct - there is no 1 = Answers one question correctly. 2 = Answers neither question correctly. partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, _____ orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues. 1c. Level of consciousness commands: The 0 = Performs both tasks correctly. _____ patient is asked to open and close the eyes 1 = Performs one task correctly. and then to grip and release the non-paretic hand. Substitute another one step 2 = Performs neither task correctly. command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (ie, https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 33/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored. 2. Best gaze: Only horizontal eye movements will be tested. Voluntary or 0 = Normal. 1 = Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If total gaze paresis is not present. the patient has a conjugate deviation of the eyes that can be overcome by voluntary or 2 = Forced deviation, or total gaze paresis not overcome by the oculocephalic reflexive activity, the score will be 1. If a maneuver. patient has an isolated peripheral nerve paresis (cranial nerves III, IV or VI), score a 1. _____ Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre- existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy. 3. Visual: Visual fields (upper and lower 0 = No visual loss. quadrants) are tested by confrontation, using finger counting or visual threat, as 1 = Partial hemianopia. 2 = Complete hemianopia. appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as 3 = Bilateral hemianopia (blind including cortical blindness). normal. If there is unilateral blindness or enucleation, visual fields in the remaining _____ eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11. 4. Facial palsy: Ask - or use pantomime to 0 = Normal symmetrical movements. _____ encourage - the patient to show teeth or 1 = Minor paralysis (flattened nasolabial raise eyebrows and close eyes. Score symmetry of grimace in response to noxious fold, asymmetry on smiling). 2 = Partial paralysis (total or near-total stimuli in the poorly responsive or non- comprehending patient. If facial paralysis of lower face). trauma/bandages, orotracheal tube, tape or https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 34/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate other physical barriers obscure the face, these should be removed to the extent 3 = Complete paralysis of one or both sides (absence of facial movement in the upper possible. and lower face). 5. Motor arm: The limb is placed in the appropriate position: extend the arms 0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in degrees, drifts down to bed, but has some effort against gravity. _____ the case of amputation or joint fusion at the shoulder, the examiner should record the 3 = No effort against gravity; limb falls. score as untestable (UN), and clearly write 4 = No movement. the explanation for this choice. UN = Amputation or joint fusion, explain:________________ 5a. Left arm 5b. Right arm 6. Motor leg: The limb is placed in the appropriate position: hold the leg at 30 0 = No drift; leg holds 30-degree position for full 5 seconds. degrees (always tested supine). Drift is 1 = Drift; leg falls by the end of the 5-second period but does not hit bed. scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency 2 = Some effort against gravity; leg falls to in the voice and pantomime, but not noxious stimulation. Each limb is tested in bed by 5 seconds, but has some effort against gravity. turn, beginning with the non-paretic leg. _____ Only in the case of amputation or joint fusion at the hip, the examiner should 3 = No effort against gravity; leg falls to bed immediately. record the score as untestable (UN), and clearly write the explanation for this choice. 4 = No movement. UN = Amputation or joint fusion, explain:________________ 6a. Left leg 6b. Right leg 7. Limb ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. 0 = Absent. _____ 1 = Present in one limb. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. 2 = Present in two limbs. The finger-nose-finger and heel-shin tests UN = Amputation or joint fusion, explain:________________ are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 35/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position. 8. Sensory: Sensation or grimace to pinprick 0 = Normal; no sensory loss. when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms [not pain with pinprick, but patient is aware of being touched. hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A 2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, score of 2, "severe or total sensory loss," should only be given when a severe or total and leg. _____ loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. 9. Best language: A great deal of information about comprehension will be 0 = No aphasia; normal. _____ 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of obtained during the preceding sections of the examination. For this scale item, the comprehension, without significant limitation on ideas expressed or form of patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet and expression. Reduction of speech and/or comprehension, however, makes conversation about provided materials to read from the attached list of sentences. Comprehension is judged from responses difficult or impossible. For example, in conversation about provided materials, here, as well as to all of the commands in the preceding general neurological exam. If examiner can identify picture or naming card content from patient's response. visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The 2 = Severe aphasia; all communication is through fragmentary expression; great need intubated patient should be asked to write. The patient in a coma (item 1a=3) will for inference, questioning, and guessing by the listener. Range of information that can automatically score 3 on this item. The examiner must choose a score for the be exchanged is limited; listener carries burden of communication. Examiner cannot patient with stupor or limited cooperation, but a score of 3 should be used only if the https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 36/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate patient is mute and follows no one-step identify materials provided from patient commands. response. 3 = Mute, global aphasia; no usable speech or auditory comprehension. 10. Dysarthria: If patient is thought to be 0 = Normal. normal, an adequate sample of speech must be obtained by asking patient to read or 1 = Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty. repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be 2 = Severe dysarthria; patient's speech is so _____ slurred as to be unintelligible in the absence rated. Only if the patient is intubated or has other physical barriers to producing speech, of or out of proportion to any dysphasia, or is mute/anarthric. the examiner should record the score as untestable (UN), and clearly write an UN = Intubated or other physical barrier, explanation for this choice. Do not tell the explain:________________ patient why he or she is being tested. 11. Extinction and inattention (formerly neglect): Sufficient information to identify 0 = No abnormality. 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to neglect may be obtained during the prior testing. If the patient has a severe visual loss bilateral simultaneous stimulation in one of the sensory modalities. preventing visual double simultaneous stimulation, and the cutaneous stimuli are 2 = Profound hemi-inattention or normal, the score is normal. If the patient _____ extinction to more than one modality; has aphasia but does appear to attend to both sides, the score is normal. The does not recognize own hand or orients to only one side of space. presence of visual spatial neglect or anosognosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable. _____ Adapted from: Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale. Extension to non- neurologists in the context of a clinical trial. Stroke 1997; 28:307. Graphic 61698 Version 8.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 37/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate Modified Rankin Scale Score Description 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent, and requiring constant nursing care and attention 6 Dead Reproduced with permission from: Van Swieten JC, Koudstaa PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19:604. Copyright 1988 Lippincott Williams & Wilkins. Graphic 75411 Version 13.0 https://www.uptodate.com/contents/mechanical-thrombectomy-for-acute-ischemic-stroke/print 38/46 7/5/23, 12:13 PM Mechanical thrombectomy for acute ischemic stroke - UpToDate ASPECTS study form The ASPECTS value is calculated from two standard axial CT cuts: one at the level of the thalamus and basal ganglia (left), and one just rostral to the basal ganglia (right). A: anterior circulation; P: posterior circulation; C: