What is the recommended management for an adult patient with acute ischemic stroke and a history of cardiovascular disease, possibly with comorbidities such as diabetes, hypertension, or atrial fibrillation, undergoing thrombectomy (thrombectomy management)?

Thrombectomy Management for Acute Ischemic Stroke

For patients with acute ischemic stroke from proximal anterior circulation occlusion, mechanical thrombectomy using stent retrievers should be performed within 6 hours of symptom onset (or up to 24 hours in carefully selected patients with favorable imaging), combined with IV alteplase when eligible, as this provides superior functional outcomes compared to medical therapy alone. 1

Patient Selection and Timing

Within 6 Hours of Symptom Onset

• Mechanical thrombectomy is the standard of care for proximal intracranial artery occlusions in the anterior circulation when arterial puncture can be performed within 6 hours. 2, 3
• Patients should receive IV r-tPA (0.9 mg/kg, maximum 90 mg) if treatment can be initiated within 3 hours (Grade 1A) or within 4.5 hours (Grade 2C) of symptom onset, followed by thrombectomy. 4, 5
• Thrombectomy should proceed even if IV thrombolysis fails to achieve revascularization or is contraindicated. 1

Extended Window (6-24 Hours)

• Thrombectomy may be performed up to 24 hours after symptom onset in patients with middle cerebral artery syndrome who have extensive ischemic brain tissue but only small areas of infarction on CT perfusion imaging. 6
• For wake-up strokes with unknown time of onset, MRI diffusion/FLAIR mismatch can identify patients within 4.5 hours who may benefit from thrombolysis. 6

Procedural Requirements

Institutional Standards

• Thrombectomy must be performed at experienced stroke centers with immediate access to cerebral angiography and credentialed interventionalists (Class I, Level of Evidence C). 4
• Facilities should define specific criteria to credential physicians performing intra-arterial procedures. 4
• Hospitals treating fewer than 5 thrombectomy patients per year have increased mortality risk, emphasizing the importance of institutional experience. 4

Technical Approach

• Current generation stent retrievers (such as Solitaire) are the preferred devices, offering excellent revascularization rates, improved clinical outcomes, shorter procedure times, and reduced complications compared to first-generation devices. 7, 1
• Large bore aspiration catheters combined with stent retrievers represent the current standard. 7

Anesthesia Management

Sedation vs. General Anesthesia

• Meta-analysis of randomized trials shows no significant difference in functional outcomes between sedation and general anesthesia when managed according to protocol. 3
• The choice should prioritize rapid workflow and maintenance of blood pressure before reperfusion. 3
• General anesthesia is indicated when: patient cannot cooperate, airway protection is needed, or severe agitation prevents safe procedure. 3

Adjunctive Medical Management

Acute Phase (First 48 Hours)

• Start aspirin 160-325 mg within 48 hours of symptom onset (Grade 1A), but delay 24 hours after IV thrombolysis. 4, 5
• Aspirin is preferred over therapeutic parenteral anticoagulation in the acute phase. 5
• Admit patients to a stroke unit for continuous monitoring of blood pressure and neurologic status. 4

Blood Pressure Management

• Before reperfusion, maintain blood pressure to preserve collateral flow—avoid aggressive lowering unless required for thrombolysis eligibility. 3
• After successful reperfusion, manage hypertension to prevent hemorrhagic transformation. 4

VTE Prophylaxis

• For patients with restricted mobility, use prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B). 4
• Avoid elastic compression stockings (Grade 2B). 4

Secondary Prevention

Antiplatelet Therapy

• For noncardioembolic stroke, long-term treatment with clopidogrel 75 mg daily or aspirin/extended-release dipyridamole 25/200 mg twice daily is preferred over aspirin alone (Grade 2B). 4, 5

Anticoagulation for Atrial Fibrillation

• For patients with atrial fibrillation, oral anticoagulation is recommended over antiplatelet therapy (Grade 1B). 4, 5
• Dabigatran is contraindicated with creatinine clearance ≤30 mL/min. 5

Critical Pitfalls to Avoid

• Do not delay thrombectomy to obtain chest radiography or extensive cardiac workup unless specific concerns exist (e.g., aortic dissection). 4
• Do not withhold thrombectomy based solely on time from symptom onset—collateral status and imaging criteria are more important determinants of outcome beyond 6 hours. 2, 6
• Avoid protocol violations during thrombolysis administration, as these significantly increase symptomatic intracranial hemorrhage risk and mortality. 4
• The 2012 American College of Chest Physicians guidelines suggested against mechanical thrombectomy (Grade 2C), but this recommendation is now obsolete given multiple subsequent randomized trials demonstrating clear benefit. 4, 1

Outcomes

• Thrombectomy increases functional independence (modified Rankin Scale 0-2) at 90 days from 28% to 44% compared to medical therapy alone. 1
• Symptomatic intracranial hemorrhage rates remain low at approximately 2% with modern techniques. 1
• Timely successful reperfusion is the single most effective treatment for acute ischemic stroke—systems of care should be optimized to maximize access. 2