Direct angiographic intervention for acute ischemic stroke with large vessel occlusion.

Background:Rapid and effective revascularization is the cornerstone of acute ischemic stroke treatment. Endovascular thrombectomy reperfusion has dramatically changed patients' outcomes with large vessel occlusions. Results of randomized controlled trials have shown that the benefit of this treatment is highly time-sensitive. The purpose of this review is to introduce a new approach to acute stroke treatment - direct angiographic intervention for selected patients. Methods & Results:We examined the issues related to the current guideline-based practice, emphasizing whether the benefit of using advanced multimodal imaging is worth the potential resultant disability generated by delayed reperfusion times. The published evidence supporting this novel concept was reviewed, its safety and feasibility discussed, and appropriate predictive tools for patient selection explored.Conclusion:This new approach may provide benefits for appropriately selected patients. Further prospective trials are needed to clarify the risk-versus-benefit of this approach.Abbreviations and Acronyms: AHA: American Heart AssociationAIS: acute ischemic strokeASA: American Stroke AssociationASPECTS: Alberta Stroke Program Early Computed Tomography ScoreCT: computed tomographyCTA: computed tomography angiographyCTP: computed tomography perfusionDMVO: distal, medium vessel occlusionDSA: digital subtraction angiographyED: Emergency DepartmentEVT: endovascular thrombectomyFD: flat detectorIA: intra-arterialIV: intravenousICH: intracerebral hemorrhageMR: magnetic resonanceMRA: magnetic resonance angiographyMSU: mobile stroke unitNIHSS: National Institutes of Health Stroke ScaleNCCT: non-contrast computed tomographyPLVO: proximal, large vessel occlusionPPV: positive predictive valuePWI: magnetic resonance perfusion-weighted imaging.