www.thaistrokesociety.

org

ISSN1905-372X

(Thai Guidelines of Endovascular Treatment

in Patients with Acute Ischemic Stroke)

Journal of

Thai Stroke Society

Volume 15 Number 2 (Supplement 1) May - August, 2016


Journal of Thai Stroke Society
ISSN 1905-372X

( TCI)
TCI 2

7 50

Email: thaistroke@gmail.com

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219 10160
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E-mail: info@fast-books.com
www.fast-books.com


(Endovascular Treatment
in Patients with Acute Ischemic Stroke)


(
)
( )

3 4.5
2558

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J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S3

Thai Guidelines of Endovascular Treatment in Patients
with Acute Ischemic Stroke
Stroke team
imaging modalities CT CT angiography MRI,
MR angiography, diffusion and perfusion images 2015
2013

..

S4

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016

(Cerebrovascular disease, Stroke) /

.. 2548 (Public Health Statistics A.D.2005)
3

1 2
(Disability Adjusted Life Year) 2
(AIS : acute ischemic stroke) 70%

2-3 Multi-Center-Randomized Controlled Trial
American Heart Association (AHA) / American stroke Association (ASA) 2558
(LVO : Large Vessel
Occlusion)

(The Association of Thai Interventional Neuroradiology:
ATIN) (Royal College of Radiologists of Thailand)
(Thai Stroke Society)

..
(ATIN) /
President of World Federation of Interventional and
Therapeutic Neuroradiology (WFITN)

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S5



(Thai Guidelines of
Endovascular Treatment in Patients with Acute Ischemic Stroke)

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J Thai Stroke Soc. Volume 15 (Suppl 1), 2016


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(conflicts of interest)

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S7

S3

S4

S5

S9

S10

S11

(Recommendation of Endovascular Treatment in Patients

with Acute Ischemic Stroke)

S17

S20

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Work flow

S8

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016

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S24



(Thai Guidelines of Endovascular Treatment in Patients
with Acute Ischemic Stroke)
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6

7

Pornpatr A. Dharmasaroja, M.D.1

Disya Ratanakorn, M.D.2
Samart Nidhinandana, M.D.3
Sirintara Singhara Na Ayudhaya, M.D.2
Anchalee Churojana, M.D.4
Sureerat Suwatcharangkoon, M.D.2
Jesada Keandoungchan, M.D.2
Aurauma Chutinet, M.D.5
Chesda Udommongkol, M.D.3
Yongchai Nilanont, M.D.4
Suchat Hanchaiphiboolkul, M.D.6
Jarturon Tantivatana, M.D.5
Kittipong Riabroi, M.D.7
Chai Kobkitsuksakul, M.D.2
Surasak Komonchan, M.D.6
Thanaboon Worakijthamrongchai, M.D.6
Ekachat Chanthanaphak, M.D.2

Abstract

Endovascular treatment has shown benefit in patients

with acute ischemic stroke in reducing morbidity and mortality. In
2015, The American Heart Association/ American Stroke Association
issue the focused update of the 2013 guidelines for the early
management of patients with acute ischemic stroke regarding
endovascular treatment. The Thai Stroke Society in cooperation
with The Royal College of Radiologists of Thailand and The
Association of Thai Interventional Neuroradiology issue the
Thai guidelines of endovascular treatment in patients with acute
ischemic stroke. Endovascular treatment is one of the treatment
options that should be performed in only hospitals with experienced,
certified and potential stroke centers. Eligible criteria are adult
patients (18 years old) with acute ischemic stroke from occlusion
of internal carotid artery and middle cerebral artery (M1 segment)
and a) prestroke MRS score 0-1, b) receiving intravenous rtPA
within 4.5 hours of stroke onset, c) NIHSS 6, d) ASPECTS score
from CT brain 6, e) treatment can be initiated (groin puncture)
within 6 hours of symptom onset. Outcomes on all patients should
be tracked. (J Thai Stroke Soc. 2016; 15 (Suppl1): S1-S29.)

Faculty of Medicine, Thammasat University

Faculty of Medicine Ramathibodi Hospital, Mahidol
University
3
Phramongkutklao Hospital and College of Medicine
4
Faculty of Medicine, Siriraj Hospital, Mahidol University
5
Faculty of Medicine, Chulalongkorn University,
King Chulalongkorn Memorial Hospital,
Thai Red Cross Society
6
Prasat Neurological Institute
7
Faculty of Medicine, Prince of Songkla University

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S9











(recanalization)
(reperfusion)
(penumbra)

(
)

45 80 5
.. 2547 .. 2549
19,997 376
1.881
multicenter, countrywide, prospective
cohort study2

2551
2553 1,222
26
( modified Rankin
Scale (mRS) 0-1
S10 J Thai Stroke Soc. Volume 15 (Suppl 1), 2016

) 3.2
14.2
4

( National Institute of Health Stroke Scale
(NIHSS) 15 )3
13


2554 2557

200
15
( mRS 0-2

)
16 66

11
82,177
13 27
42

meta-analysis4
(recanalization
rates)
24


(spontaneous recanalization), 46

, 63
,
68

84 mechanical
thrombectomy

(endovascular treatment)

Endovascular

treatment Intra-arterial treatment

5

endovascular treatment

5

Multicenter Randomized
Clinical Trial of Endovascular Treatment for
Acute Ischemic Stroke in Netherlands (MR
CLEAN)6

anterior circulation
endovascular treatment 6
( 500 )
endovascular treatment (233 , median age
65.8 , median NIHSS 17, median ASPECTS 9)
(267 , median age
65.7 , median NIHSS 18, median ASPECTS 9)

- (445
( 89))
randomization

- Retrievable stents
endovascular treatment 89

-
randomization (204
196 )
endovascular treatment
260

- (recanalization)
endovascular treatment
(75.4
32.9, OR 6.27, 95%CI 4.03 - 9.74)

- (
mRS 0-2) endovascular treatment
(
32.6 19.1, OR 2.05, 95%CI
1.36 - 2.71)

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S11

- new
ischemic stroke different vascular territory
90 endovascular
( 5.6 0.4
)

groin puncture first reperfusion

30
( groin
puncture iv alteplase
alteplase )

- procedure-related
complications distal embolization 8.6
(20/233 ), vessel dissections (4 ) 1.7
vessel perforation 2 ( 0.9)

- successful
reperfusion ( Thrombolysis in Cerebral
Infarction (TICI) score of 2b 3
complete filling of the expected vascular territory)
72.4 endovascular group
31

Endovascular Treatment for
Small Core and Anterior Circulation Proximal
Occlusion with Emphasis on Minimizing CT to
Recanalization Times (ESCAPE)7

anterior circulation 12
small infarct core ( ASPECTS
6-10 ) CTA moderate to good
collateral circulation (filling of 50% of middle
cerebral artery pial arterial circulation)
endovascular treatment (165 , median
age 71 , median NIHSS 16, median ASPECTS
9) (150 , median age 70 ,
median NIHSS 17, median ASPECTS 9)

endovascular treatment

- 90 ( mRS
0-2) endovascular treatment
( 53
29.3, OR 1.8, 95%CI 1.4 - 2.4, p-value < 0.001)
endovascular treatment
( 10.4
19, OR 0.5, 95%CI 0.3 1.0, p-value
= 0.04)

( 3.6 2.7, OR 1.4,

95%CI 0.4 4.7, p-value = 0.75)

- procedure-related
complications 18 4
serious complications (hematoma at access site
3 perforation of middle cerebral artery
1 )

- (
endovascular treatment; 72.7, median
stroke onset to rt-PA 110 ;
78.7, median stroke onset to rt-PA 125
)
randomization

Extending the Time for
Thrombolysis in Emergency Neurological
Deficits-Intra-Arterial (EXTEND-IA)8
internal carotid artery
middle cerebral artery
4.5

CT perfusion : ischemic penumbra infarct
core 70
endovascular thrombectomy Solitaire
stent retriever (35 , median age 68.6 ,

- endovascular treatment
retrieval stent 86.1 ( 77
Solitaire stent)
first reperfusion 241
CT first reperfusion 84
S12 J Thai Stroke Soc. Volume 15 (Suppl 1), 2016

median NIHSS 17, median stroke onset to hospital

arrival 78 ) (35 , median
age 70.2 , median NIHSS 13, median stroke
onset to hospital arrival 80 ) reperfusion
24 early neurological improvement
(NIHSS 8 )
endovascular
treatment

- endovascular treatment
endovascular treatment 210
endovascular
treatment

successful
revascularization
86 ( restoration of flow
50 stroke-affected territory)

- CT perfusion
endovascular treatment infarct
core endovascular treatment
(18.9
19.6 ) penumbra
(105 116 ) (
25 CT perfusion
)

- reperfusion
24 endovascular
treatment ( 100
37, p-value < 0.001)

- early neurological improvement
endovascular treatment
( 80 37, p-value
=0.002) ( mRS 0-2)
90 endovascular
treatment ( 71 40, p-value
=0.01)

Randomized Trial of
Revascularization with Solitaire FR Device
versus Best Medical Therapy in the Treatment
of Acute Stroke Due to Anterior Circulation
Large Vessel Occlusion Presenting within Eight
Hours of Symptom Onset (REVASCAT)9

8 18-85
proximal anterior circulation NIHSS
6 exclude
( ASPECT
7 non-contrast CT
6 diffusion-weighted MRI)
endovascular thrombectomy
Solitaire stent retriever (103 , median age
65.7 , median NIHSS 17, median ASPECTS 7.0,
median stroke onset to randomization 223 )
(103 , median age 67.2 ,
median NIHSS 17, median ASPECTS 8.0, median
stroke onset to randomization 226 )
global disability score ( modified Rankin Scale)
90
endovascular treatment

- endovascular treatment
endovascular treatment 269

70 ( 68)
118
median time
revascularization 355

-
80 ( 78)

105

(
mRS 0-2) 90 endovascular
treatment ( 43.7 28.2, OR 2.1

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S13

(95% CI 1.1-4.0))
( 18.4 15.5
, p=0.60))
( 1.9 )

Solitaire With the Intension
For Thrombectomy as Primary Endovascular
Treatment (SWIFT PRIME) trial10
intracranialinternal carotid
artery middle cerebral artery M1
(
CT perfusion small core of infarct
large hypoperfused tissue)

endovascular treatment
6
endovascular thrombectomy stent
retriever (98 , median age 65 , median NIHSS
17, median ASPECTS 9.0, median stroke onset
to start of intravenous t-PA 111 )
(98 , median age 66.3 , median NIHSS
17, median ASPECTS 9.0, median stroke onset
to start of intravenous t-PA 117 ) global
disability score ( modified Rankin Scale)
90
endovascular treatment

- endovascular treatment
endovascular treatment 224

reperfusion
88 ( reperfusion
50 TICI 2b 3)

(
mRS 0-2) 90 endovascular
treatment ( 60
35, OR 1.7 (95% CI 1.23-2.33, p-value
< 0.001))
( 9 12 ,
p=0.5)

S14 J Thai Stroke Soc. Volume 15 (Suppl 1), 2016

( 0 3 ,
p-value=0.12)

MR CLEAN,
ESCAPE, EXTEND-IA, REVASCAT SWIFT
PRIME
internal carotid artery middle cerebral
artery infarct core

endovascular treatment ( stent retriever

devices)
reperfusion

3 ( 1
2) endovascular treatment
multidisciplinary team
neurointerventionists

 1 Inclusion Criteria
MR CLEAN6
(N=500)

ESCAPE7 (N=315)

6 12

EXTEND-IA8
(N=70)

4.5

REVASCAT9
(N=206)

SWIFT PRIME10
(N=196)

endovascular
treatment
6

18

adults
no age
(no upper-age limit) restriction

18-85

18-80 12

NIHSS

N/A

no clinical
severity
restriction

8-29 12

Proximal,
Proximal, anterior
anterior circula- circulation arteries
tion arteries
(ICA, M1, M2)
(ICA, M1, M2,
A1 or A2)

Proximal,
anterior
circulation
arteries (ICA,
M1, M2)

Proximal,
anterior
circulation
arteries
(ICA, M1, M2)

Proximal, anterior
circulation
arteries (ICA,
M1, M2)

Imaging
selection

CT perfusion:
infarct core
<70 ml and
salvageable
brain tissue

CT: small infarct

core (ASPECTS
7-10) or DWIMRI (ASPECTS
6-10)

CT perfusion:
small infarct core
(<50 ml) and
salvageable
brain tissue

Devices in
Endovascular
arm

Retrievable stent Retrievable stent

89
86

Solitaire stent
retriever
100

Solitaire stent
retriever
100

Solitaire stent
retriever
100

CT, multiphase
CTA: small infarct
core, (ASPECTS
6-10), moderate to
good
collateralization

( Dharmasaroja PA. Endovascular treatment in patients with acute ischemic stroke. J Thai Stroke Soc 2015; 14: 124-34.)

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S15

S16 J Thai Stroke Soc. Volume 15 (Suppl 1), 2016

18 (14-21)

21%

mortality (%)
19%

2.7%

29%

125

79%

17(12-20)

Control
(N=150)

Perforation 1

10%

3.6%

53%

72%

185

110

73%

16(13-20)

IAT* (N=165)

ESCAPE7 (N=315)

20%

6%

40%

145

100%

13(9-19)

Control
(N=35)

Perforation1,
Emboli 2

9%

71%

86%

210

127

100%

17(13-20)

IAT* (N=35)

EXTEND-IA8 (N=70)

16%

1.9%

28%

105

78%

17(12-19)

Control
(N=103)

Perforation 5,
Emboli 5

18%

1.9%

44%

66%

269

118

68%

17(14-20)

IAT* (N=103)

REVASCAT9 (N=206)

12%

3%

36%

117

100%

17(13-19)

Control
(N=98)

Subarachno-id
hemorrh-age 4

9%

60%

88%

224

111

100%

17(13-20)

IAT* (N=98)

SWIFT PRIME10 (N=196)

(*IAT=intraarterial treatment (endovascular treatment))( Dharmasaroja PA. Endovascular treatment in patients with acute ischemic stroke. J Thai Stroke Soc; 14: 124-34.)

Emboli 13

7.7%

symptomatic ICH (%) 6.4%

Device
complications13

33%

mRS 0-2 at 90 days 19%

(%)

22%

59%

Reperfusion rate;
TICI 2B/3 (%)

85

260

87

87%

17(14-22)

IAT*
(N=233)

median time from

stroke onset to groin
puncture (minutes)

median time from

stroke onset to iv
rtPA(minutes)

Intravenous rtPA(%) 91%

Median
NIHSS(range)

Control
(N=267)

MR CLEAN6 (N=500)

2 Combination of endovascular treatment and intravenous rtPA

 Mechanical Thrombectomy

aspiration

stent retriever

Penumbra
2009 PIVOTAL TRIAL
prospective multicenter single-arm study
penumbra
MERCI clot extraction
Penumbra
MERCI 11
MULTI
MERCI12, PROACT II 13, CLOTBUST 14
Penumbra
(revascularization)
80%
Modified Rankin score 2 90

(salvageable ischemic area)

Aspiration
Stent retriever
stent retriever 2014-2015
MR CLEAN6, ESCAPE7, EXTEND-IA8, SWIFT
PRIME10
modified Rankin
score intravenous
thrombolysis

Aspiration Penumbra ACE, Penumbra

MAX
ADAPT (A Direct Aspiration First Pass Technique
for stroke)

(separator)

(Emboli
to New Territories; ENT ) stent


stent retriever
aspiration stent aspiration catheter
15 new
technique aspiration catheter
retrospective cohort studies
randomized control trial
stent retriever

(
)

(Recommendation of Endovascular Treatment

in Patients with Acute Ischemic Stroke)16
1.

( ++,
I, Class I, level of evidence A)
2.

7 ( ++,
I, Class I, level of evidence A)

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S17

2.1 mRS 0-1

2.2
4.5
2.3
internal carotid artery (ICA) middle cerebral
artery (MCA) (M1)
2.4 18
2.5 NIHSS 6
2.6 ASPECTS 6
2.7
(groin puncture)
6
(
)
3.

6

(
+/-, III, Class IIb, level
of evidence C)
4.
anterior circulation


6

( +,
III, Class IIa, level of evidence C);

,

, ,
(coagulopathy)
(anticoagulant)
5. M2 M3-MCA,
anterior cerebral artery (ACA), vertebral artery (VA)
Basilar artery (BA)

S18 J Thai Stroke Soc. Volume 15 (Suppl 1), 2016

(groin puncture) 6
(
)
( +/-, III, Class IIb,
level of evidence C)
6.
18


(groin puncture) 6

( +/-, III, Class IIb,
level of evidence C)
7.
ICA, M1- MCA
mRS 1
, ASPECTS 6
NIHSS 6
(

)( +/-, II,
Class IIb, level of evidence B)
8.

(
-, II, Class III, level of
evidence B)
9.
stent retrievers MERCI
device ( ++, I,
Class I, level of evidence A)
stent retrievers
( +/-, II,
Class IIb, level of evidence B)

10. stent
retrievers proximal balloon guide
catheter large bore distal access catheter
cervical guide catheter
( +, III, Class IIa,
level of evidence C)
11.
reperfusion TICI 2b/3
( ++,
I, Class I, level of evidence A);

6 ( +/-,
II, Class IIb, level of evidence B)
12. angioplasty stenting

(
+/-, III, Class IIb, level of
evidence C)
13.
MCA
6
(
++, II, Class I, level of evidence
B)

( ++,
IV, Class I, level of evidence E)
14.
6
( +/-,
III, Class IIb, level of evidence C)
15.
conscious sedation
general anesthesia

( +/-,
III, Class IIb, level of evidence C)

(Imaging)
1.

( ++,
I, Class I, level of evidence A) nonenhanced
CT

2.

noninvasive intracranial vascular study

noninvasive vascular
study noninvasive vascular study

noninvasive intracranial
vascular study ( ++,
I, Class I, level of evidence A)
3.
CT CTA MR MRA
CTperfusion or diffusion- and perfusion-weighted
imaging
(
+/-, III, Class IIb, level of evidence
C) -

infarct core,
collateral flow penumbra

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S19


1.

( ++,
I, Class I, level of evidence A)

22.

( ++,
I, Class I, level of evidence A)
3.




( +/-,
III, Class IIb, level of evidence C)
4.

(certified neurointerventionists)*

S20 J Thai Stroke Soc. Volume 15 (Suppl 1), 2016

( ++, IV,
Class I, level of evidence E)
( *
)

(guideline)


(gold
standards) "

(. , .
9 .. 2554,
http://www.rcpt.org/index.php/news/20-26-09-24-09-2012.
html 10 .. 2558)


1. Hanchaiphiboolkul S, Poungvarin N, Nidhinandana
S, Suwanwela NC, Puthkhao P, Towanabut S, et al.
Prevalence of stroke and stroke risk factors in
Thailand: Thai Epidemiology Stroke (TES) study.
J Med Assoc Thai 2011;94:427-36.
2. Nilanont Y, Nidhinandana S, Suwanwela NC,
Hanchaiphiboolkul S, Pimpak T, Tatsanavivat P,
et al. Quality of acute ischemic stroke care in
Thailand: A prospective multicenter countrywide
cohort study. J Stroke Cerebrovasc Dis 2014;
23: 213-9.
3. Dharmasaroja PA, Muengtaweepongsa S,
Pattaraarchachai J. Clinical course, prognostic factors
and long-term outcomes of malignant middle cerebral
artery infarctions in the modern era. Neurol India
2016; 64: 436-41.
4. Rha JH, Saver JL. The impact of recanalization on
ischemic stroke outcome: a meta-analysis. Stroke
2007;38:967-73.
5. Dharmasaroja PA. Endovascular treatment in patients
with acute ischemic stroke. J Thai Stroke Soc 2015;
14: 124-134.
6. Berkhemer OA, Fransen PSS, Beumer D, van den
Berg LA, Lingsma HF, Yoo AJ, et al. A randomized
trial of intraarterial treatment for acute ischemic
stroke. N Engl J Med 2015;372:11-20.
7. Goyal M, Demchuk AM, Menon BK, Eesa M,
Rempel JL, Thornton J, et al. Randomized assessment
of rapid endovascular treatment of ischemic stroke.
N Engl J Med 2015;372: 1019-30.
8. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM,
Churilov L, Yassi N, et al. Endovascular therapy for
ischemic stroke with perfusion-imaging selection.
N Engl J Med 2015; 372: 1009-18.
9. Jovin TG, Chamorro A, Cobo E, de Miquel MS,
Molina CA, Rovira A, et al. Thrombectomy within
8 hours after symptom onset in ischemic stroke.
N Engl J Med 2015 April 17. [Epub ahead of print]
PMID: 25882510

10. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI,

Pereira VM, et al. Stent-Retriever Thrombectomy
after intravenous t-PA vs t-PA alone in Stroke.
N Engl J Med 2015 April 17. [Epub ahead of print]
PMID:25882376
11. The Penumbra Pivotal Stroke Trial Safety and
Effectiveness of a New Generation of Mechanical
Devices for Clot Removal in Intracranial Large
Vessel Occlusive Disease. Stroke 2009; 40:2761-8.
12. Smith WS, Sung G, Saver J, Budzik R, Duckwiler
G, Liebeskind DS, et al. Mechanical thrombectomy
for acute ischemic stroke: final results of the Multi
MERCI trial. Stroke 2008; 39: 120512.
13. Furlan A, Higashida R, Wechsler L, Gent M, Rowley
H, Kase C, et al. Prolyse in Acute Cerebral
Thromboembolism. Intra-arterial prourokinase for
acute ischemic stroke. The PROACT II study:
a randomized controlled trial. JAMA 1999; 282:
200311.
14. Alexandrov AV, Woiner AW, Grotta JC; CLOTBUST:
design of a randomized trial of ultrasound-enhanced
thrombolysis for acute ischemic stroke. J Neuroimaging
2004; 14:108-12.
15. Turk AS, Turner R, Spiotta A, Vargas J, Holmstedt
C, Ozark S et al. Comparison of endovascular
treatment approaches for acute ischemic stroke: cost
effectiveness, technical success, and clinical
outcomes. J Neurointerv Surg 2015;7:666-70.
16. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh
BL, Jauch EC, et al. 2015 American Heart Association/
American Stroke Association focused update of the
2013 guidelinesfor the early management of patients
with acute ischemic stroke regarding endovascular
treatment. Guideline for healthcare professionals
from the American Heart Association/ American
Stroke Association. Stroke 2015; 46: 3024-39.

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S21

(Strength of Recommendation)

++

(cost effective)
(strongly recommend)

+


(recommend)

+/-

(neither recommend nor against)

-

(against)

--

(strongly against)
(Quality of Evidence)

I
(systematic review)
- (randomizecontrolled clinical trials)
- 1
(a well-designed, randomize-controlled, clinical
trial)

II

(non-randomized, controlled, clinical

S22 J Thai Stroke Soc. Volume 15 (Suppl 1), 2016

trials)
(well-designed, non-randomized,
controlled clinical trial)
(cohort)
(case control
analytic studies)
/
(multiple time
series)

.. 2480

III
(descriptive studies)
(fair-designed, controlled
clinical trial)

IV

(consensus)

(anecdotal
report)

( , .
. 2554 www.surgeons.or.th/
s p a w 2 / u p l o a d s / fi l e s / C P G % 2 0 h a n d b o o k . p d f
9 2558)

J Thai Stroke Soc. Volume 15 (Suppl 1), 2016 S23

randomized clinical trials meta-analysis randomized clinical

trials registry studies

1 randomized non-randomized clinical trials, meta-analysis, registry studies

randomized non-randomized observational registry studies

meta-analyses physiological mechanistic studies

Level of evidence A

Level of evidence B

Level of evidence C

Level of evidence E

( Powers WJ, et al. Stroke 2015; 46: 3024-39.)

(procedure)

Class IIb

Class III

Class II

Class IIa

(procedure)

Class I

American Heart Association


Workflow for combination of endovascular treatment and intravenous thrombolysis in patients
with acute ischemic stroke
Patients suspected MCA infarction,
onset within 3 hours, NIHSS > 6

Endovascular team/service is
available.

Endovascular team/service is not

available.

No contraindication for
intravenous thrombolysis and
endovascular treatment

No contraindication for
intravenous thrombolysis

Patients with contraindication of

intravenous thrombolytic
treatment

CT and CTA
Non-contrast CT

Non-contrast CT

+/- CTP
CBC,CR, coagulogram,DTX
Notify neurointerventionist
CT brain : ASPECT score > 6

CT brain : no contraindication for

rtPA

Admit stroke unit and treat with

standard guideline

CTA shows symptomatic

occlusion of ICA, M1

Patient: inform & consent

Patient: inform & consent
Intravenouos rtPA 0.9 mg/kg
(max.90 mg)

Intravenouos rtPA 0.9 mg/kg

(max.90 mg)

Endovascular treatment within 6

hours of symptom onset
0.9%NSS iv rate 1-2 ml/kg/hour
(depending on clinical and UD of
patient)
0.9%NSS iv rate 1-2 ml/kg/hour
(depending on clinical and UD of
patient)

FU NIHSS immediate after

procedure, 2, 24 hours and per
protocol

FU NIHSS immediate after

procedure, 2, 24 hours and per
protocol

FU CT 24 hours after intervention

or when patient getting worse

FU creatinine level od x3 days

Notify FU ./.

FU CT 24 hours after intervention

or when patient getting worse

Patients should receive

endovascular therapy with a stent
retriever if they meet all the
following criteria (a) prestroke
mRS score 0 to 1,(b) acute
ischemic stroke receiving
intravenous r-tPA within 4.5 hours
of onset according to guidelines
from professional medical
societies,(c) causative occlusion of
the internal carotid artery or
proximal MCA (M1),(d) age 18
years,(e) NIHSS score of 6,(f)
ASPECTS of 6, and (g) treatment
can be initiated (groin puncture)
within 6 hours of symptom onset

Notify FU ./.

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Suspected stroke
Hx, PE, Vital signs

Onset > 8 hr 7 day

Onset < 8 hr
Stroke FAST Track

(<24 hr in basilar disease*Stroke FAST track)

Immediate CT brain at ER
Lab: DTX, PG, CBC, BUN, Cr, PT, PTT, CXR, EKG

Immediate CT brain at ER
Lab: DTX, PG, CBC, BUN, Cr, PT, PTT, CXR, EKG

Hemorrhagic stroke
Ischemic stroke

Ischemic stroke
Consult NS

Onset < 4.5 hr

Onset 4.5 8 hr
(<24 hr in basilar disease*)

Consider
IV thrombolysis++
CTA neck/ CTP (MRI/MRA brain and neck**) ++

Large vessel occlusion

No large vessel occlusion

Consider
Thrombectomy

Stroke unit
Remark
* Posterior circulation stroke onset < 24 hr, consider as Stroke FAST track
** MRI/MRA brain and neck

++

(1) Posterior circulation stroke

(2) Contraindication for contrast media
(3) Unclear onset <12 hr (Last seen normal <12 hr)

Notify Intervention

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S26 J Thai Stroke Soc. Volume 15 (Suppl 1), 2016

Stroke care map

Notify interventionist, Anesthesiologist

Large vessel occlusion

or severe stenosis

Large vessel occlusion

or severe stenosis

or stenosis

1.CTA arch of aorta

2. inform consent
Endovascular treatment
CrCl < 40

Basilar artery occlusion

CT+CTA or MRI+MRA Brain

and onset 12 hours

Basilar artery occlusion

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Consider Endovascular treatment / mechanical thrombectomy

Stroke care map

No occlusion

or MRI+MRA Brain (Optional)

CT + CTA brain include arch of aorta

Neurointerventionist

notify staff on service stroke

IV line 2 , Lab

Onset 4.5-6 hours

Acute Ischemic Stroke Protocal

CT + CTA brain include arch of aorta

No large vessel occlusion

20-30 rt-PA

rT-PA

CT Brain non contrast

Activate stroke fast track

IV line 2 , Lab
notify staff on service stroke
Neurointerventionist

Onset < 4.5 hours


Stroke Protocol 3rd Edition 2014

Form 1

Division of Neurology, Department of Medicine

Ramathibodi Hospital, Mahidol University
Protocol A (possible rt-PA/ endovascular treatment candidate)
Stroke onset < 3 hr - < 24 hr
Non contrast CT brain
CTA brain** (+ CT perfusion***) or MRI/ MRA*; if NIHSS > 6
A1: Onset < 3 hr

Check eligible IV rt-PA < 3h

(see IV rt-PA assessment form Form2)

A2: Onset 3 - < 4.5 hr

A3: Onset
4.5 - < 6 hr (for anterior circulation) or
4.5 - < 24 hr (for posterior circulation)

Check eligible IV rt-PA 3 - < 4.5h

Check eligible IA rt-PA or

Mechanical thrombectomy *

(see IV rt-PA assessment form Form 3)

Not eligible IV rt-PA*

Eligible IV rt-PA

A3 protocol

Obtain informed consent

Administer IV rt-PA

[see IA rt-PA (Form 4A) or Mechanical

thrombectomy (Form 4B) assessment form]

& Notify Interventionist

Eligible IV rt-PA

Eligible IA rt-PA or
Mechanical thrombectomy

Obtain informed consent

Administer IV rt-PA

NIHSS > 6 and

intracranial
ICA or proximal MCA
(M1), extracranial ICA*,
BA occlusion*
Check eligible Mechanical
thrombectomy
(see Mechanical thrombectomy Form 4B assessment form) &

Notify Interventionist

Intracranial ICA,
proximal MCA
(M1) occlusion

Extracranial ICA*,
BA occlusion*

Obtain informed consent

Administer IA rt-PA or Mech thrombectomy
(see IA rt-PA assessment form Form 4A or
Mechanical thrombectomy assessment form Form

Eligible Mechanical thrombectomy

Obtain informed consent

Mech thrombectomy
Admit to Acute Stroke Unit or appropriate ward

Not eligible IA rt-PA or

Mechanical thrombectomy

Eligibility for IV or IA rt-PA is listed in the rt-PA assessment form.

* Expert opinion, ** Expert opinion with inform consent for patients with high risk for CIN
*** Not done if onset < 4.5 hours, optional if onset > 4.5 hours

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