• Give IV rtPA, even if considering intra-arterial management
• Early intra-arterial fibrinolysis in select patients at qualified facility
• Outcomes with mechanical thrombectomy devices not fully established but can be useful in achieving recanalization in select patients
• Stent retrievers preferred to coil devices; Penumbra System® vs stent retrievers not yet characterized
• Emergent intracranial angioplasty and/or shunting not recommended
The Bottom Line: Two mechanical embolectomy trials in acute stroke published in 2012, SWIFT and TREVO 2, support the use of stent retriever devices over the use of the Merci Retriever®.
Unchanged: IV rtPA should be administered to eligible patients even if intra-arterial interventions are being considered.
Revised: Select patients with MCA strokes of < 6 hours duration who are not IV rtPA candidates can benefit from intra-arterial fibrinolysis, which should be administered at an experienced stroke center with rapid cerebral angiography capabilities and defined qualification criteria. Though their ultimate impact on patient outcomes has yet to be determined, the Merci, Penumbra System, Solitaire™ FR, and Trevo® devices can be useful in recanalizing the occluded artery, either alone or in combination with pharmacologic fibrinolysis. Intra-arterial fibrinolysis or mechanical thrombectomy can be considered in patients unqualified for IV fibrinolysis.
New: Minimizing delays in administering intra-arterial fibrinolysis improves outcomes. Stent retrievers such as Solitaire FR and Trevo are preferred to coil retrievers such as Merci, whereas the effectiveness of the Penumbra System vs stent retrievers is, as of the new guideline's publication, not yet determined. In patients with a large artery stroke who have not responded to IV fibrinolysis, intra-arterial fibrinolysis and mechanical thrombectomy are reasonable approaches. Emergent intracranial angioplasty and/or shunting do not have proven usefulness, nor does the use of these approaches in the extracranial carotid or vertebral arteries in unselected patients.