Clinical protocol of the ischemic stroke patients treatment
Abstract
Today in Ukraine there is no single standardized protocol for the treatment of patients in the acute period of ischemic stroke using modern methods of diagnosis and treatment, which include thrombolytic therapy and endovascular treatment. This protocol was created and implemented in Scientific-practical Center of endovascular neuroradiology, NAMS of Ukraine and is based on the latest recommendations of AHA/ASA and ESO, as well as registers of patients with ischemic stroke.
The main purpose of this publication is the creation and implementation of «instructions» for the diagnosis and selection of objective tactics for treating patients in the acute period of ischemic stroke.
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References
Global Burden of Disease Study 2019 (GBD 2019). Seattle, WA: Institute for Health Metrics and Evaluation (IHME), University of Washington, 2020 (http://ghdx.healthdata.org/gbd-results-tool).
Kim J, Thayabaranathan T, Donnan GA, et al. Glo-bal Stroke Statistics 2019. Int J Stroke. 2020 Oct; 15(8):819-838. doi: 10.1177/1747493020909545.
Saver JL. Time is brain - quantified. Stroke. 2006;37:263-6. doi: 10.1161/01.STR.0000196957.55928.ab
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995 Dec 14; 333(24):1581-7. doi: 10.1056/NEJM199512143332401
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;359:1317-29. doi: 10.1056/NEJMoa0804656
Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: Pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768-74. doi: 10.1016/S0140-6736(04)15692-4.
Külkens S, Hacke W Thrombolysis with alteplase for acute ischemic stroke: review of SITS-MOST and other Phase IV studies. Expert Rev Neurother. 2007 Jul;7(7):783-8. doi: 10.1586/14737175.7.7.783.
Barreto AD. Intravenous thrombolytics for ischemic
stroke. Neurotherapeutics. 2011 Jul; 8(3):388-99. doi: 10.1007/s13311-011-0049-x.
Saqqur M, Uchino K, Demchuk AM, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke. 2007;38:948-54. doi: 10.1161/01.STR.0000257304.21967.ba
Bhatia R, Hill MD, Shobha N, et al. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke. 2010;41:2254-8. doi: 10.1161/STROKEAHA.110.592535
Malhotra K, Gornbein J, Saver JL. Ischemic strokes due to large-vessel occlusions contribute disproportionately to stroke-related dependence and death: a review. Front Neurol. 2017;8:651. doi: 10.3389/fneur.2017.00651.
Dozois A, Hampton L, Kingston CW, et al. PLUMBER Study (Prevalence of Large Vessel Occlusion Strokes in Mecklenburg County Emergency Response). Stroke. 2017;48(12):3397-9. https://doi.org/10.1161/STROKEAHA.117.018925
Smith WS, Lev MH, English JD, et al. . Significance of large vessel intracranial occlusion causing acute ischemic stroke and TIA. Stroke. 2009;40:3834–40. doi: 10.1161/STROKEAHA.109.561787
Rai AT, Seldon AE, Boo S, et al. A population-based incidence of acute large vessel occlusions and thrombectomy eligible patients indicates significant potential for growth of endovascular stroke therapy in the USA. J Neurointerv Surg. 2017 Aug; 9(8):722-6. doi: 10.1136/neurintsurg-2016-012515
Rennert RC, Wali AR, Steinberg JA,et al. Epidemiology, natural history, and clinical presentation of large vessel ischemic stroke. Neurosurgery. 2019 Jul 1; 85(suppl_1):S4-S8. doi: 10.1093/neuros/nyz042
Beumer D, Mulder MJHL, Saiedie G, et al. Occurrence of intracranial large vessel occlusion in consecutive, non-referred patients with acute ischemic stroke. Neurovascular Imaging. 2016;2 doi: 10.1186/s40809-016-0022-5
Adams HP Jr, Davis PH, Leira EC, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999;53:126-31. doi: 10.1212/wnl.53.1.126
Brott T, Adams HP, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989;20:864-70. doi: 10.1161/01.STR.20.7.864
Cerejo R, Cheng-Ching E, Hui F, et al. Treatment of patients with mild acute ischemic stroke and associated large vessel occlusion. J Clin Neurosci. 2016;30:60-4. doi: 10.1016/j.jocn.2015.12.029
Haussen DC, Lima FO, Bouslama M, et al. Thrombectomy versus medical management for large vessel occlusion strokes with minimal symptoms: an analysis from STOPStroke and GESTOR cohorts. J Neurointerv Surg. 2018;10:325-9. doi: 10.1136/neurintsurg-2017-013243
Haussen DC, Bouslama M, Grossberg JA, et al. Too good to intervene? Thrombectomy for large vessel occlusion strokes with minimal symptoms: an intention-to-treat analysis. J Neurointerv Surg. 2017;9:917-21. doi:10.1136/neurintsurg-2016-012633
Mokin M, Masud MW, Dumont TM, et al. Outcomes in patients with acute ischemic stroke from proximal intracranial vessel occlusion and NIHSS score below 8. J Neurointerv Surg. 2014;6:413-7. doi:10.1136/neurintsurg-2013-010720
Dargazanli C, Arquizan C, Gory B, et al. Mechanical thrombectomy for minor and mild stroke patients harboring large vessel occlusion in the anterior circulation: a multicenter cohort study. Stroke. 2017;48:3274-81. doi:10.1161/STROKEAHA.117.018113
Zaidat OO, Castonguay AC, Gupta R, et al. North American Solitaire stent retriever acute stroke registry: post-marketing revascularization and clinical outcome results. J Neurointerv Surg. 2014;6:584-8. doi:10.1136/neurintsurg-2013-010895
Mokin M, Abou-Chebl A, Castonguay AC, et al. Real-world stent retriever thrombectomy for acute ischemic stroke beyond 6 hours of onset: analysis of the NASA and TRACK registries. J Neurointerv Surg. 2018:neurintsurg-2018-014272. doi:10.1136/neurintsurg-2018-014272
Broeg-Morvay A, Mordasini P, Bernasconi C, et al. Direct mechanical intervention versus combined intravenous and mechanical intervention in large artery anterior circulation stroke: a matched-pairs analysis. Stroke. 2016;47:1037-44. doi:10.1161/STROKEAHA.115.011134
Desai SM, Haussen DC, Aghaebrahim A, et al. Thrombectomy 24 hours after stroke: beyond DAWN. J Neurointerv Surg. 2018;10:1039-42. doi:10.1136/neurintsurg-2018-013923
Alawieh A, Chatterjee A, Feng W, et al. Thrombectomy for acute ischemic stroke in the elderly: a ‘real world’ experience. J Neurointerv Surg. 2018;10:1209-17. doi:10.1136/neurintsurg-2018-013787
Son S, Kang DH, Hwang YH, et al. Efficacy, safety, and clinical outcome of modern mechanical thrombectomy in elderly patients with acute ischemic stroke. Acta Neurochir. 2017;159:1663-9. doi:10.1007/s00701-017-3269-y
Le Bouc R, Clarençon F, Meseguer E, et al. Efficacy of endovascular therapy in acute ischemic stroke depends on age and clinical severity. Stroke. 2018;49:1686–94. doi:10.1161/STROKEAHA.117.020511
Goyal M, Menon BK, van Zwam W, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. The Lancet. 2016;387:1723-31. doi:10.1016/S0140-6736(16)00163-X
Delgado Almandoz JE, Kayan Y, Young ML, et al. Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques. J Neurointerv Surg 2016;8:1123-8. doi:10.1136/neurintsurg-2015-012122
Massari F, Henninger N, Lozano JD, et al. ARTS (Aspiration-Retriever Technique for Stroke): Initial clinical experience. Interv Neuroradiol. 2016;22:325-32. doi:10.1177/1591019916632369
Maus V, Behme D, Kabbasch C, et al. Maximizing first-pass complete reperfusion with save. Clin Neuroradiol. 2018;28. doi:10.1007/s00062-017-0566-z
McTaggart RA, Tung EL, Yaghi S, et al. Continuous aspiration prior to intracranial vascular embolectomy (CAPTIVE): a technique which improves outcomes. J Neurointerv Surg. 2017;9:1154-9. doi:10.1136/neurintsurg-2016-012838
Nikoubashman O, Alt JP, Nikoubashman A, et al. Optimizing endovascular stroke treatment: removing the microcatheter before clotretrieval with stent-retrievers increases aspiration flow. J Neurointerv Surg. 2017;9(5):459-62. doi: 10.1136/neurintsurg-2016-012319
Maegerlein C, Mönch S, Boeckh-Behrens T, et al. PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy – evaluation of a double embolic protection approach in endovascular stroke treatment. J Neurointerv Surg. 2017;Dec. 8:PII:neurintsurg-2017-013558. doi: 10.1136/neurintsurg-2017-013558
Srinivasan A, et al. State-of-the-art imaging of acute stroke. Radiographics. 2006 Oct;26 Suppl 1:S75-95. doi: 10.1148/rg.26si065501
Hill MD, et al. Alberta Stroke Program early computed tomography score to select patients for endovascular treatment: Interventional Management of Stroke (IMS)-III Trial. Stroke. 2014 Feb;45(2):444-9. doi: 10.1161/STROKEAHA.113.003580
Barber PA, Demchuk AM, Zhang J, et al. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355 (9216): 1670-4. doi: 10.1016/s0140-6736(00)02237-6
Puetz V, Sylaja PN, Coutts SB, et al. Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke. 2008;39 (9):2485-90. doi: 10.1161/STROKEAHA.107.511162
Weber R, van Hal R, Strack P, et al. Incidence of acute kidney injury after computed tomography angiography ± computed tomography perfusion followed by thrombectomy in patients with stroke using a postprocedural hydration protocol. J Am Heart Assoc. 2020 Feb 18;9(4):e014418. doi: 10.1161/JAHA.119.014418
Liebeskind DS, et al. Collaterals at angiography and outcomes in the Interventional Management of Stroke (IMS) III trial. Stroke. 2014 Mar;45(3):759-64. doi: 10.1161/STROKEAHA.113.004072
Zaidat OO, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke. 2013 Sep;44(9):2650-63. doi: 10.1161/STROKEAHA.113.001972
Broderick JP, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 2013 Mar 7;368(10):893-903. doi: 10.1056/NEJMoa1214300
LeCouffe NE, Kappelhof M, Treurniet KM et al. 2B, 2C, or 3: What should be the angiographic target for endovascular treatment in ischemic stroke? Stroke. 2020 Jun;51(6):1790-6. doi: 10.1161/STROKEAHA.119.028891. Epub 2020 May 13.
Liebeskind DS, Bracard S, Guillemin F, et al. eTICI reperfusion: defining success in endovascular stroke therapy. J Neurointerv Surg. 2019;11:433-8. doi: 10.1136/neurintsurg-2018-014127
Naragum V, Jindal G, Miller T, et al. Functional independence after stroke thrombectomy using thrombolysis in cerebral infarction grade 2c: a new aim of successful revascularization. World Neurosurg. 2018;119:e928-e933. doi: 10.1016/j.wneu.2018.08.006
Dargazanli C, Fahed R, Blanc R, et al.; ASTER Trial Investigators. Modified thrombolysis in cerebral infarction 2C/Thrombolysis in cerebral infarction 3 reperfusion should be the aim of mechanical thrombectomy: insights from the ASTER Trial (Contact Aspiration Versus Stent Retriever for Successful Revascularization). Stroke. 2018;49:1189-96. doi: 10.1161/STROKEAHA.118.020700
Desai SM, Rocha M, Molyneaux BJ, et al. Thrombectomy 6-24 hours after stroke in trial ineligible patients. J Neurointerv Surg. 2018;10:1033-7. doi:10.1136/neurintsurg-2018-013915
Kim Y, Lee S, Abdelkhaleq R, et al. Utilization and availability of advanced imaging in patients with acute ischemic stroke. Circ Cardiovasc Qual Outcomes. 2021;14(4):e006989. doi:10.1161/CIRCOUTCOMES.120.006989
Nogueira RG, Haussen DC, Liebeskind D, et al; Trevo Registry and DAWN Trial Investigators. Stroke imaging selection modality and endovascular therapy outcomes in the early and extended time windows. Stroke. 2021;52(2):491-7. https://doi.org/10.1161/STROKEAHA.120.031685
Demeestere J, Garcia-Esperon C, Garcia-Bermejo P, et al. Evaluation of hyperacute infarct volume using ASPECTS and brain CT perfusion core volume. Neurology. 2017;88(24):2248-53. doi:10.1212/WNL.0000000000004028
Siegler JE, Messé SR, Sucharew H, et al. Noncontrast CT versus perfusion-based core estimation in large vessel occlusion: the Blood Pressure after Endovascular Stroke Therapy Study. J Neuroimaging. 2020 Mar;30(2):219-226. doi: 10.1111/jon.12682
Nogueira RG, Ribó M. Endovascular treatment of acute stroke. Stroke. 2019;50(9):2612-8. doi:10.1161/STROKEAHA.119.023811
García-Tornel Á, Campos D, Rubiera M, et al. Ischemic core overestimation on computed tomography perfusion. Stroke. 2021;52(5):1751-60. doi:10.1161/STROKEAHA.120.031800
Thanh N Nguyen, 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. Published online November 8, 2021. doi:10.1001/jamaneurol.2021.4082
Sun CHJ, Ribo M, Goyal M, et al. Door-to-puncture: a practical metric for capturing and enhancing system processes associated with endovascular stroke care, preliminary results from the rapid reperfusion registry. J Am Heart Assoc. 2014;3(2):e000859. doi:10.1161/JAHA.114.000859
Haussen DC, Dehkharghani S, Rangaraju S, et al. Automated CT perfusion ischemic core volume and noncontrast CT ASPECTS (Alberta Stroke Program Early CT Score): correlation and clinical outcome prediction in large vessel stroke. Stroke. 2016;47(9):2318-22. doi:10.1161/STROKEAHA.116.014117
Nannoni S, Ricciardi F, Strambo D, et al. Correlation between ASPECTS and core volume on CT perfusion: impact of time since stroke onset and presence of large-vessel occlusion. AJNR Am J Neuroradiol. 2021;42(3):422-8. doi:10.3174/ajnr.A6959
Desai SM, Tonetti DA, Molyneaux BJ, et al. Interaction between time, ASPECTS, and clinical mismatch. J Neurointerv Surg. 2020;12(9):911-4. doi:10.1136/neurintsurg-2020-015921
Nagel S, Herweh C, Pfaff JAR, et al. Simplified selection criteria for patients with longer or unknown time to treatment predict good outcome after mechanical thrombectomy. J Neurointerv Surg. 2019;11(6):559-62. doi:10.1136/neurintsurg-2018-014347
Bouslama M, Haussen DC, Rodrigues G, Barreira C, Frankel M, Nogueira RG. Novel selection paradigms for endovascular stroke treatment in the extended time window. J Neurol Neurosurg Psychiatry. 2021;jnnp-2020-325284. doi:10.1136/jnnp-2020-325284
Lopez-Rivera V, Abdelkhaleq R, Yamal J-M, et al. Impact of initial imaging protocol on likelihood of endovascular stroke therapy. Stroke. 2020;51(10):3055-63. doi:10.1161/STROKEAHA.120.030122
Gautheron V, Xie Y, Tisserand M, et al. Outcome after reperfusion therapies in patients with large baseline diffusion-weighted imaging stroke lesions: a THRACE trial (Mechanical Thrombectomy After Intravenous Alteplase Versus Alteplase Alone After Stroke) subgroup analysis. Stroke. 2018;49:750-3. doi:10.1161/STROKEAHA.117.020244
Rebello LC, Bouslama M, Haussen DC, et al. Endovascular treatment for patients With acute stroke who have a large ischemic core and large mismatch imaging profile. JAMA Neurol. 2017;74:34-40. doi:10.1001/jamaneurol.2016.3954
Mourand I, Abergel E, Mantilla D, et al. Favorable revascularization therapy in patients with ASPECTS ≤5 on DWI in anterior circulation stroke. J Neurointerv Surg. 2018;10:5-9. doi:10.1136/neurintsurg-2017-013358
Gilgen MD, Klimek D, Liesirova KT, et al. Younger stroke patients with large pretreatment diffusion-weighted imaging lesions may benefit from endovascular treatment. Stroke. 2015;46:2510-6. doi:10.1161/STROKEAHA.115.010250
Román LS, Menon BK, Blasco J, et al. Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data. Lancet Neurol. 2018;17:895-904. doi:10.1016/S1474-4422(18)30242-4
Campbell BCV, Majoie C, Albers GW, et al.; HERMES collaborators. Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data. Lancet Neurol. 2019;18:46-55. doi:10.1016/S1474-4422(18)30314-4
Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11-20. doi:10.1056/NEJMoa1411587
Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009-18. doi:10.1056/NEJMoa1414792
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;372:2285-95. doi:10.1056/NEJMoa1415061
Bracard S, Ducrocq X, Mas JL, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 2016;15:1138-47. doi:10.1016/S1474-4422(16)30177-6
Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296-306. doi:10.1056/NEJMoa1503780
Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019-30. doi:10.1056/NEJMoa1414905
Evans JW, Graham BR, Pordeli P, et al. Time for a time window extension: insights from late presenters in the ESCAPE trial. AJNR Am J Neuroradiol. 2018;39:102-6. doi:10.3174/ajnr.A5462
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;378:708-18. doi:10.1056/NEJMoa1713973
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;378:11-21. doi:10.1056/NEJMoa1706442
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;316:1279-88. doi:10.1001/jama.2016.13647
Zaidat OO, Castonguay AC, Nogueira RG, et al. TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry. J Neurointerv Surg. 2018;10:516-24. doi:10.1136/neurintsurg-2017-013328
Weber R, Nordmeyer H, Hadisurya J, et al. Comparison of outcome and interventional complication rate in patients with acute stroke treated with mechanical thrombectomy with and without bridging thrombolysis. J Neurointerv Surg. 2017;9:229-33. doi:10.1136/neurintsurg-2015-012236
Coutinho JM, Liebeskind DS, Slater LA, et al. Combined intravenous thrombolysis and thrombectomy vs thrombectomy alone for acute ischemic stroke: a pooled analysis of the SWIFT and STAR studies. JAMA Neurol. 2017;74:268-74. doi:10.1001/jamaneurol.2016.5374
Goyal N, Tsivgoulis G, Frei D, et al. Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion. Neurology. 2018;90:e1274-82. doi:10.1212/WNL.0000000000005299
Seners P, Turc G, Maïer B, et al. Incidence and predictors of early recanalization after intravenous thrombolysis: a systematic review and meta-analysis. Stroke. 2016;47:2409-12. doi:10.1161/STROKEAHA.116.014181
Menon BK, Al-Ajlan FS, Najm M, et al. Association of clinical, imaging, and thrombus characteristics with recanalization of visible intracranial occlusion in patients with acute ischemic stroke. JAMA. 2018;320:1017-26. doi:10.1001/jama.2018.12498
Leslie-Mazwi T, Chandra RV, Baxter BW, et al. ELVO: an operational definition. J Neurointerv Surg. 2018;10:507-9. doi:10.1136/neurintsurg-2018-013792
Altenbernd J, Kuhnt O, Hennigs S, et al. Frontline ADAPT therapy to treat patients with symptomatic M2 and M3 occlusions in acute ischemic stroke: initial experience with the Penumbra ACE and 3MAX reperfusion system. J Neurointerv Surg. 2018;10:434-9. doi:10.1136/neurintsurg-2017-013233
Premat K, Bartolini B, Baronnet-Chauvet F, et al. Single-center experience using the 3max reperfusion catheter for the treatment of acute ischemic stroke with distal arterial occlusions. Clin Neuroradiol. 2018;28:553-62. doi:10.1007/s00062-017-0594-8
Haussen DC, Lima A, Nogueira RG. The Trevo XP 3×20 mm retriever (‘Baby Trevo’) for the treatment of distal intracranial occlusions. J Neurointerv Surg. 2016;8:295-9. doi:10.1136/neurintsurg-2014-011613
Mokin M, Fargen KM, Primiani CT, et al. Vessel perforation during stent retriever thrombectomy for acute ischemic stroke: technical details and clinical outcomes. J Neurointerv Surg. 2017;9:922-8. doi:10.1136/neurintsurg-2016-012707
Lindsberg PJ, et al. Long-term outcome after intravenous thrombolysis of basilar artery occlusion. JAMA. 2004 Oct 20;292(15):1862-6. doi: 10.1001/jama.292.15.1862
Kumar G, et al. Recanalization of acute basilar artery occlusion improves outcomes: a metaanalysis. J Neurointerv Surg. 2015 Dec;7(12):868-74. doi: 10.1136/neurintsurg-2014-011418
Schonewille WJ, et al. Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol. 2009 Aug;8(8):724-30. doi: 10.1016/S1474-4422(09)70173-5
Baek JM, et al. Acute basilar artery occlusion: outcome of mechanical thrombectomy with Solitaire stent within 8 hours of stroke onset. AJNR Am J Neuroradiol. 2014 May;35(5):989-93. doi: 10.3174/ajnr.A3813
European Stroke Organisation (ESO) – European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke. J Neurointerv Surg. 2019 Feb 26;neurintsurg-2018-014569. doi: 10.1136/neurintsurg-2018-014569
Van der Hoeven EJ, Schonewille WJ, Vos JA, et al. The Basilar Artery International Cooperation study (basics): study protocol for a randomised controlled trial. Trials 2013;14:200. doi:10.1186/1745-6215-14-200
Heldner MR, Jung S, Zubler C, et al. Outcome of patients with occlusions of the internal carotid artery or the main stem of the middle cerebral artery with NIHSS score of less than 5: comparison between thrombolysed and non-thrombolysed patients. J Neurol Neurosurg Psychiatry 2015;86:755–60.doi:10.1136/jnnp-2014-308401
Rajajee V , Kidwell C , Starkman S , et al . Early MRI and outcomes of untreated patients with mild or improving ischemic stroke. Neurology 2006;67:980–4.doi:10.1212/01.wnl.0000237520.88777.71

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