Question 4

Briefly describe the indications, post-procedure management and procedural complications of endovascular clot retrieval (ECR) for acute stroke.

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College answer

Indications:                                                                                                                            2 Marks

  • Ischaemic stroke with proven large-vessel occlusion on CT Angiogram (naming vessels not necessary) (1 mark)
  • Onset of symptoms up to 24 hours if CT imaging is supportive. (0.5 marks)
  • Functionally independent prior to stroke (0.5 marks)

Post-procedure management:                                                                                           4 Marks

  • Admission to monitored environment (e.g. stroke unit / HDU), usually intubated for procedure, so may describe extubation plan
  • Observe vascular access site for complications
  • Neurological monitoring for haemorrhagic transformation or further ischaemic complications
  • Blood Pressure Target: control as per agreed targets
  • Aspirin, 24-hours after thrombolysis and exclusion of haemorrhagic complications
  • Other neuroprotective measures (BSL, Na, position, temperature, CO2 etc.)
  • Oral intake after speech pathology assessment in patients with clinical neurological deficit
  • Mechanical DVT prophylaxis/stress ulcer prophylaxis.
  • Longer term management dependent on extent of deficit

Complications:                                                                                                                      4 Marks

    1. Direct device-related vascular injury:
      • vessel perforation
      • symptomatic intracranial haemorrhage
      • subarachnoid haemorrhage
      • arterial dissection
      • emboli to new territories
      • vasospasm
    • Vascular access site complications:
      • dissection
      • pseudoaneurysm
      • retro-peritoneal Haematoma
      • infection
    • Contrast-related:
      • Allergy
      • Renal Injury
    • Any complications related to anaesthesia

Examiners Comments:

Many candidates provided only generic responses without specific detail.


Briefly, they said.

  • Indications:
    • Ischaemic stroke with large vessel occlusion
    • Substantial neurological deficit, NIHSS ≥ 5
    • Timeframe criteria:
      • Less than six hours: "broad clinical and imaging criteria"
      • 6-24 hour window: "significant volume of salvageable tissue"
    • Good level of premorbid independence
  • Complications:
    • Bleeding (though the risk of symptomatic ICH is no higher)
    • Cerebral oedema
    • Vascular access site complications
  • Evidence:
    • ​​​​​​​DAWN trial: 206 patients, 49% had good functional outcome vs 13%
    • DEFUSE-3 trial: 186 patients, 47% had good functional outcome vs 17%
  • Post-procedure management:
  1. E​​​​​​xtubate early, if able.
  2.  Mechanical ventilation focuses on maintenance of normoxia and normocapnia
  3. Blood pressure control:
    1. Aim for SBP <140-160 for fully revascularised patients
    2. Aim for MAP 10-20% over normal baseline and SBP <185 for partially revascularised patients
  4. Minimise sedation and maximise the opportunity for regular reassessment
    Also, scan their head after the first 24 hrs.
  5. Control of electrolytes to prevent AF
  6. Maintenance of neutral fluid balance
  7. Glucose control: hyperglycaemia is harmful
  8. Antiplatelets after 24 hrs (earlier if they had an endovascular stent)
  9. Fever is harmful: paracetamol is recommended


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