• 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, Almandoz Josser E Delgado JE Department of Interventional Neuroradiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA., Justin F Fraser, Donald Frei, Chirag D Gandhi, Don V Heck, Steven W Hetts, M Shazam Hussain, Michael Kelly, Richard Klucznik, Seon-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, and Standards and Guidelines Committee of the Society of NeuroInterventional Surgery (SNIS).
• Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
• J Neurointerv Surg. 2017 Mar 1; 9 (3): 316-323.

ObjectiveTo 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.MethodsUsing 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.ResultsThis 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.ConclusionsPatients 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.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

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