The Code Stroke Overhaul: From Lytics to Thrombectomy

A Practical Guide for the Modern Critical Care Physician

Dr Neeraj Manikath , claude.ai

Abstract

The landscape of acute ischemic stroke management has undergone a revolutionary transformation over the past decade. While intravenous thrombolysis once represented the pinnacle of acute stroke therapy, mechanical thrombectomy (MT) has emerged as the dominant intervention for large vessel occlusions (LVO), fundamentally reshaping stroke systems of care. This review examines contemporary evidence-based approaches to acute stroke management, focusing on expanded time windows through advanced imaging selection, direct-to-angiography suite pathways, and the nuanced post-thrombectomy care that bridges interventional radiology and critical care medicine.

Introduction

The 2015 publication of landmark trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT) established mechanical thrombectomy as standard of care for proximal large vessel occlusions within 6 hours of symptom onset.1-5 Subsequent paradigm shifts emerged with DAWN (2018) and DEFUSE-3 (2018), which extended the therapeutic window to 24 hours using perfusion imaging selection criteria.6,7 Today's stroke systems must integrate rapid triage, advanced neuroimaging protocols, and streamlined care pathways while navigating the complex post-intervention period.

The evolution from "time is brain" to "tissue is brain" represents more than semantic distinction—it embodies a fundamental reconceptualization of acute stroke as a heterogeneous condition requiring individualized assessment rather than rigid temporal cutoffs.8

Expanding the Window: Imaging Selection for Late Arrivals

The Paradigm Shift: From Clock to Physiology

The traditional 4.5-hour window for IV thrombolysis and early 6-hour thrombectomy window were predicated on population-level averages that failed to account for collateral circulation variability and individual ischemic tolerance. Advanced imaging modalities now permit identification of patients with salvageable tissue far beyond these arbitrary temporal boundaries.

Perfusion Imaging: The Foundation

CT Perfusion (CTP) vs. MRI Perfusion:

Both modalities assess the ischemic penumbra—the hypoperfused but viable tissue surrounding the infarct core. CTP offers advantages in speed and availability, while MRI provides superior posterior fossa visualization and avoids radiation exposure.9

Key Parameters:

Cerebral Blood Flow (CBF): <30% of contralateral hemisphere suggests core
Mean Transit Time (MTT): Prolonged in both core and penumbra
Time to Maximum (Tmax): >6 seconds defines critical hypoperfusion
Mismatch Ratio: Tmax >6s volume / Core volume ≥1.8 (DEFUSE-3 criteria)7

Pearl: In DAWN trial criteria, clinical-core mismatch alone sufficed for patient selection (6-24 hours), demonstrating that significant disability with minimal infarction suggests robust penumbra even without perfusion imaging.6

DAWN and DEFUSE-3: The Evidence Base

DAWN Trial (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes):

Enrollment 6-24 hours from last known well
Clinical-imaging mismatch: severe deficit (NIHSS ≥10) with small core (<21 mL if age ≥80 or NIHSS ≥20; <31 mL if age <80 and NIHSS 10-19; <51 mL if age <80 and NIHSS ≥20)
Number needed to treat: 2.8 for functional independence
Modified Rankin Score (mRS) 0-2: 49% vs. 13% (control)6

DEFUSE-3 Trial:

Enrollment 6-16 hours from last known well
Target mismatch ratio ≥1.8 with mismatch volume ≥15 mL
Core volume <70 mL
mRS 0-2: 45% vs. 17% (control)7

Oyster: Both trials excluded patients with extremely large cores (>70-100 mL), yet real-world registries suggest potential benefit even in some patients exceeding these thresholds, particularly with good collaterals. Clinical judgment remains paramount.10

Wake-Up Strokes: A Special Population

Approximately 25% of ischemic strokes occur during sleep. The "last known well" time technically extends to when the patient fell asleep, often exceeding traditional windows. WAKE-UP trial demonstrated efficacy of IV alteplase in patients with DWI-FLAIR mismatch (visible on DWI but not FLAIR, suggesting <4.5 hour equivalent age).11

Practical Hack: For wake-up strokes presenting early, consider tandem IV thrombolysis + thrombectomy if imaging criteria met. The brief delay for IV therapy rarely impacts thrombectomy timing when given in parallel during preparation.

Collateral Assessment: The Unsung Hero

Robust leptomeningeal collaterals preserve penumbra and predict better outcomes. Multiple grading systems exist:

CT Angiography-Based:

Miteff Score: Grade 0 (absent) to 3 (100% filling)
Tan Score: Regional assessment of collateral extent
Multiphase CTA: Superior temporal resolution showing delayed collateral filling12

Pearl: Multiphase CTA requires no additional contrast and significantly improves collateral assessment compared to single-phase imaging. Push for institutional protocols incorporating this technique.

Imaging Protocol Optimization

Recommended Acute Stroke Imaging Battery:

Non-contrast CT: Exclude hemorrhage, assess early ischemic changes (ASPECTS score)
CTA head and neck: Identify LVO, assess collaterals, evaluate for tandem lesions
CTP: If presenting >6 hours or wake-up stroke; acquire during CTA with same contrast bolus
Alternative: MRI with DWI/FLAIR/MRA/PWI if available rapidly

Time Target: Door-to-imaging completion <20 minutes; door-to-groin puncture <90 minutes for direct transfers.13

Hack: Pre-hospital notification should trigger automatic "stroke imaging protocol" activation, eliminating delays for individual test ordering. The entire suite completes in <10 minutes.

Direct to Angio Suite: Bypassing the ED for Eligible Patients

The Rationale: Every Minute Matters

Despite 24-hour windows for selected patients, earlier reperfusion consistently correlates with superior outcomes. Each 15-minute delay reduces probability of good outcome by 4%.14 Traditional workflows—ED triage, examination, imaging, interpretation, neurology consultation, neurointerventionalist activation—introduce unnecessary delays for patients clearly requiring thrombectomy.

Patient Selection for Direct Transfer

Ideal Candidates:

Pre-hospital LAMS (Los Angeles Motor Scale) or RACE (Rapid Arterial Occlusion Evaluation) score suggesting LVO
NIHSS ≥6 (sensitivity for LVO)
Last known well <6 hours (or <24 hours with mobile stroke unit CT showing small core)
No contraindications to angiography
Presenting directly to thrombectomy-capable center

Exclusion Criteria:

Hemodynamic instability requiring resuscitation
Known or suspected intracerebral hemorrhage
Seizure at onset (mimics)
Rapid improvement to NIHSS <6

Pearl: The FAST-MAG trial demonstrated feasibility and safety of pre-hospital magnesium administration, validating the concept that EMS can initiate sophisticated stroke protocols. Similar infrastructure enables direct-to-angio decisions.15

Mobile Stroke Units: The Ultimate Bypass

MSU-equipped ambulances with onboard CT, point-of-care laboratory, and telemedicine-enabled neurologists represent the logical extreme of early intervention. The BEST-MSU trial demonstrated 1-hour earlier treatment times and improved 90-day outcomes.16

Oyster: MSU implementation requires substantial investment (~$1-2 million per unit plus operational costs). Cost-effectiveness depends on regional stroke volume, geography, and existing EMS transport times. Not universally applicable but transformative in high-volume urban centers.

Workflow Design: Orchestrating the Bypass

Pre-Hospital Phase:

EMS activation: Stroke screening tool (LAMS/RACE/CPSS)
Pre-notification: Direct to neurointerventionalist on-call
Mobile communication: Real-time vital signs, glucose, clinical status
Destination determination: Nearest thrombectomy center (not just stroke-ready)

In-Hospital Phase (Direct to Angio Suite Protocol):

Angio suite preparation: Begins during EMS transport
Streamlined consent: Often verbal initially; family contacted en route
Parallel processing:
- IV access, labs drawn in angio suite
- Simultaneous CT/CTA in neuroradiology (if immediately adjacent) OR
- Cone-beam CT in angio suite (emerging technology)
IV alteplase: Administered in angio suite pre-procedure if eligible
Groin puncture goal: <30 minutes from hospital arrival

Hack: Create physical proximity. Institutions with CT scanners adjacent to or within the angio suite complex reduce door-to-puncture times by 20-30 minutes.17

Addressing the "What About IV tPA?" Question

Current Evidence:

DIRECT-MT and SKIP trials (Asian populations) showed non-inferiority of thrombectomy alone vs. combined IV thrombolysis + thrombectomy for proximal LVO18,19
However, DIRECT-SAFE (more international) suggested potential benefit of combination therapy20
Meta-analyses show marginal benefit favoring combination, particularly for successful recanalization rates21

Practical Approach:

If no delay: Administer IV alteplase en route to angio suite (door-to-needle <20 min)
If delay anticipated: Proceed directly to thrombectomy; don't delay for IV therapy
Tandem occlusions or distal targets: Consider IV therapy to treat emboli beyond thrombectomy reach

Pearl: Tenecteplase (0.25 mg/kg IV bolus) shows promise as alteplase alternative with easier administration and potentially superior recanalization for LVO. Multiple trials ongoing; some centers already adopting off-label.22

Safety Concerns and Mitigations

Bypassing ED examination risks missing:

Hemorrhagic stroke (mitigated by imaging)
Stroke mimics (seizure, hypoglycemia, conversion disorder)
Medical instability (MI, sepsis)

Mitigations:

Brief focused assessment by angio suite team (2 minutes)
Point-of-care glucose universally
Telemedicine neurologist can perform virtual NIHSS
Low threshold for ED re-routing if clinical uncertainty

Oyster: False-positive LVO rates range 15-30% with prehospital screening tools. Over-triage is acceptable—delays to true LVO patients from under-triage cause greater harm than unnecessary angio suite activations.23

Institutional Implementation

Checklist for Direct-to-Angio Programs:

☐ 24/7 thrombectomy capability
☐ Neurointerventionalist buy-in and availability
☐ Pre-hospital provider training and protocols
☐ Integrated communication system (EMS-hospital)
☐ Anesthesia availability (general anesthesia for select cases)
☐ Nursing staff trained in acute angio suite stroke care
☐ Quality metrics and continuous feedback loop

Managing the Post-Thrombectomy Patient in the ED

While many thrombectomy patients transfer directly to neuro-ICU, ED management of immediate post-procedure complications and stabilization remains essential, particularly when ICU beds unavailable or for patients initially bypassing ED.

The First Hour: Critical Decision Points

Immediate Post-Procedure Assessment:

Neurological Status
- Repeat NIHSS (compare to pre-procedure baseline)
- Assess for hyperperfusion syndrome: severe headache, seizures, focal deficits worsening paradoxically
- Pearl: Dramatic early improvement (NIHSS drop ≥8 points) predicts excellent outcomes but monitor for hemorrhagic transformation
Blood Pressure Management
- Most critical intervention in post-thrombectomy care
- Target: <140/90 mmHg for first 24 hours if recanalization successful (TICI 2b-3)
- Target: <180/105 mmHg if recanalization failed
- Rationale: Successful reperfusion restores pressure to damaged blood-brain barrier, increasing hemorrhage risk
- Agents: IV nicardipine (preferred for titratable control), labetalol, clevidipine
- Hack: Start nicardipine drip prophylactically if SBP >140 mmHg rather than waiting for escalation—preventing BP spikes is easier than treating them24
Groin Access Site
- Assess for hematoma, bleeding, distal pulses
- Maintain bed rest per institutional protocol (2-6 hours typical)
- Check activated clotting time if heparin used during procedure

Hemorrhagic Transformation: Recognition and Management

Risk Factors:

Large infarct core (ASPECTS <6)
Delayed reperfusion
Poor collaterals
Aggressive BP elevation post-procedure
Concomitant IV thrombolysis
Anticoagulation

Types:

HI-1/HI-2 (Hemorrhagic Infarction): Petechial hemorrhage, usually asymptomatic
PH-1 (Parenchymal Hematoma): <30% of infarct, minimal mass effect
PH-2: >30% of infarct with significant mass effect—associated with poor outcomes25

Surveillance Strategy:

Routine post-thrombectomy imaging: 24-hour non-contrast CT for all patients
Urgent imaging if: Neurological deterioration, new headache, declining consciousness, seizure

Management of Symptomatic ICH:

Reverse anticoagulation:
- IV thrombolysis cases: Consider tranexamic acid 1g IV if <3 hours from tPA
- Hold antiplatelet agents
- Platelets if thrombocytopenic (<100K) or recent clopidogrel with clinical deterioration
Blood pressure: Liberalize targets to SBP 140-180 to maintain cerebral perfusion
ICP management: Elevate HOB 30°, osmotherapy if indicated
Neurosurgical consultation: Consider for cerebellar hematomas or space-occupying supratentorial hemorrhage

Oyster: Routine platelet transfusion for ICH after IV thrombolysis may worsen outcomes (PATCH trial)—reserve for active bleeding or coagulopathy.26

Medical Complications: Proactive Management

1. Cerebral Edema

Peaks 3-5 days post-stroke but early identification crucial
Risk factors: Large MCA territory infarction (>50%), younger age, early ischemic changes
Monitoring: Serial neurological exams q1-2h, threshold for repeat imaging
Management:
- Hyperosmolar therapy: Mannitol 0.25-1 g/kg or hypertonic saline (goal Na 145-155)
- HOB elevation 30°
- Avoid hyperthermia, hyperglycemia, hypoxia
- Pearl: Decompressive hemicraniectomy reduces mortality in malignant MCA syndrome if performed <48 hours; discuss early with neurosurgery for appropriate candidates27

2. Aspiration Pneumonia

20-30% of acute stroke patients
Prevention is key:
- NPO until formal swallow evaluation
- HOB ≥30° at all times
- Meticulous oral care
Hack: Bedside water swallow test (3 oz) has 94% sensitivity for aspiration risk; safe for early screening in alert patients28

3. Seizures

Occur in 5-10% post-stroke; higher risk with hemorrhagic transformation
Management: Levetiracetam 500-1000 mg IV load preferred (no hepatic metabolism, fewer interactions than phenytoin)
No role for prophylactic anticonvulsants unless specific indications

4. Hyperglycemia

Independently predicts poor outcomes and hemorrhagic transformation
Target: 140-180 mg/dL
Method: IV insulin infusion for persistent hyperglycemia >180; avoid hypoglycemia (<70 mg/dL) equally harmful29

Antithrombotic Management: The 24-Hour Dilemma

Post-Thrombectomy Antiplatelet Therapy:

Standard Approach (No IV tPA):

If no hemorrhagic transformation on 24-hour CT: Start aspirin 325 mg daily
Consider dual antiplatelet therapy (DAPT): Aspirin + clopidogrel 75 mg for 21-90 days if minor stroke (NIHSS <3) per POINT/CHANCE trials30,31
Oyster: Post-thrombectomy patients typically have moderate-severe strokes (NIHSS >6), thus DAPT evidence less clear; many centers use monotherapy

If IV Thrombolysis Given:

Wait 24 hours post-tPA before starting antiplatelet therapy
Obtain CT to exclude hemorrhage before initiation

Anticoagulation for Atrial Fibrillation:

Delay 3-14 days depending on infarct size
Small infarct (<1.5 cm): Consider day 3-4
Moderate infarct: Day 7-10
Large infarct (>5 cm) or hemorrhagic transformation: Day 14 or individualized32
Pearl: Direct oral anticoagulants (DOACs) preferred over warfarin for faster therapeutic levels and superior safety profile

Temperature, Glucose, and Blood Pressure: The "Big Three"

These three parameters disproportionately impact outcomes yet are frequently suboptimally managed.

Temperature:

Target: <37.5°C (normothermia)
Each 1°C elevation above 37°C increases mortality risk
Management: Acetaminophen 650 mg q4-6h scheduled (not PRN); cooling devices for refractory fever; investigate infectious sources

Glucose:

Addressed above; merits emphasis as modifiable target

Blood Pressure:

Reviewed extensively above; maintain strict adherence to protocols

Hack: Create a "Stroke Bundle" order set with automatic scheduled acetaminophen, insulin protocol, and nicardipine parameters preloaded to ensure compliance with these critical interventions.

Disposition Planning from the ED

ICU Admission Indications:

NIHSS >10
Fluctuating or deteriorating neurological status
Hemorrhagic transformation with mass effect
Requiring vasoactive medications or airway protection
Large infarct at risk for malignant edema

Step-Down/Telemetry Admission:

NIHSS 4-10, stable
Requiring cardiac monitoring (atrial fibrillation, troponin elevation)

Floor Admission (with stroke unit):

NIHSS <4, stable, routine 24-hour imaging completed

Pearl: Comprehensive stroke centers with dedicated neuro-ICUs should be preferentially utilized; outcomes improve with specialized nursing care and intensivist-neurologist co-management.33

Communication and Documentation

Key elements to communicate:

Pre-thrombectomy NIHSS and post-thrombectomy NIHSS (improvement = surrogate for successful reperfusion)
Occlusion location and TICI score (2b-3 = successful recanalization)
IV thrombolysis timing if given
BP management requirements
Antiplatelet timing and plan
24-hour imaging plan
Any procedural complications (dissection, perforation, embolization to new territory)

Emerging Horizons and Future Directions

Medium Vessel Occlusions (MeVO):

Occlusions beyond M1 (M2/M3) and beyond ICA/proximal basilar
Smaller devices (3-mm aspiration catheters) expanding technical feasibility
Trials ongoing (ESCAPE-MeVO); practice currently variable34

Artificial Intelligence:

Automated LVO detection from CTA (e.g., RapidAI, Viz.ai) with sensitivity >90%
Direct neurointerventionalist notification, reducing delays by 20-30 minutes
Cloud-based platforms enabling remote interpretation35

Tenecteplase:

Simplified administration may enable pre-hospital or drip-and-ship paradigms
Potentially superior for LVO recanalization

Neuroprotection:

Decades of failed trials, but renewed interest with nerinetide (ongoing trials)
Hypothermia revisited with selective brain cooling technologies

Practical Pearls and Oysters: Summary

Pearls:

Multiphase CTA adds no time/contrast but dramatically improves collateral assessment
Nicardipine drip started prophylactically prevents BP spikes better than reactive treatment
Decompressive hemicraniectomy decisions should occur <48 hours—discuss early
Water swallow test enables safe early dysphagia screening
"Stroke Bundle" order sets ensure compliance with temperature/glucose/BP targets

Oysters:

DAWN/DEFUSE core thresholds are guidelines, not absolutes—good collaterals may justify treatment outside criteria
Mobile stroke units are cost-effective only in specific contexts—not universally applicable
Direct-to-angio protocols accept 15-30% false-positive rates for LVO—this is appropriate
Routine platelet transfusion for post-tPA ICH may harm; reserve for specific indications
DAPT evidence in post-thrombectomy patients less established than minor stroke populations

Critical Hacks:

Pre-notification triggers automatic imaging protocol—no delays for individual orders
Physical proximity of CT to angio suite reduces door-to-puncture by 20-30 minutes
Brief delay for IV alteplase acceptable if given in parallel during thrombectomy preparation
Scheduled acetaminophen (not PRN) for all stroke patients in first 24 hours
Start nicardipine prophylactically if post-thrombectomy SBP >140 mmHg

Conclusion

The modern approach to acute ischemic stroke has evolved from a time-dependent emergency to a physiology-driven, imaging-selected intervention with expanded therapeutic windows and optimized care pathways. Thrombectomy has supplanted thrombolysis as the definitive treatment for large vessel occlusions, but success depends on systems integration—from pre-hospital recognition through post-procedure management.

Critical care physicians play pivotal roles in patient selection through perfusion imaging interpretation, facilitating direct-to-angio suite workflows, and managing the complex post-thrombectomy period where hemorrhagic transformation, cerebral edema, and medical complications require vigilant attention. Mastery of blood pressure management, recognition of reperfusion injury patterns, and proactive prevention of secondary complications separate adequate from excellent post-thrombectomy care.

As the field continues to advance with medium vessel interventions, artificial intelligence integration, and novel neuroprotective strategies, the fundamental principles remain: rapid assessment, individualized treatment selection based on tissue viability, and meticulous post-intervention management. The code stroke of 2025 bears little resemblance to that of 2010—and the evolution continues.

References

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Appendix: Quick Reference Tables

Table 1: Thrombectomy Time Windows and Selection Criteria

Time Window	Selection Criteria	Key Trial	Level of Evidence
0-6 hours	LVO (ICA, M1, basilar) + ASPECTS ≥6	MR CLEAN, ESCAPE, SWIFT PRIME	Class I, Level A
6-16 hours	Target mismatch (ratio ≥1.8, volume ≥15 mL, core <70 mL)	DEFUSE-3	Class I, Level A
6-24 hours	Clinical-core mismatch (see DAWN criteria)	DAWN	Class I, Level A
Wake-up stroke	DWI-FLAIR mismatch or perfusion imaging selection	WAKE-UP + extrapolation	Class IIa, Level B

Table 2: Post-Thrombectomy Blood Pressure Targets

Clinical Scenario	SBP Target	Duration	Agent of Choice
Successful recanalization (TICI 2b-3)	<140 mmHg	24 hours	Nicardipine 5-15 mg/hr
Failed recanalization (TICI 0-2a)	<180 mmHg	24 hours	Nicardipine or labetalol
Symptomatic ICH	140-180 mmHg	Individualized	Liberalize carefully
After 24 hours (no complications)	<180/105 mmHg	Until discharge	Oral agents

Table 3: Anticoagulation Timing After Stroke in Atrial Fibrillation

Infarct Size	Timing to Start AC	Rationale
TIA or small (<1.5 cm)	Day 3-4	Low hemorrhagic risk
Moderate (1.5-5 cm)	Day 7-10	Balance thrombotic vs hemorrhagic risk
Large (>5 cm)	Day 14+	High hemorrhagic transformation risk
With hemorrhagic transformation	Delay 2-4 weeks	Individualize based on bleeding severity

Table 4: Common Post-Thrombectomy Complications and Management

Complication	Incidence	Early Signs	Initial Management
Hemorrhagic transformation	5-10% symptomatic	Neurological decline, headache	Stat CT, BP control, reverse coagulopathy
Cerebral edema	10-20% (large infarcts)	Declining GCS, anisocoria	Osmotherapy, HOB elevation, neurosurgery consult
Groin hematoma	2-5%	Swelling, pain, hypotension	Hold pressure, ultrasound, vascular surgery if expanding
Contrast-induced nephropathy	5-15%	Rising Cr at 48-72h	Hydration, avoid nephrotoxins, monitor UOP
Aspiration pneumonia	20-30%	Fever, infiltrate, hypoxia	NPO, antibiotics, dysphagia evaluation

Case-Based Learning: Applying the Principles

Case 1: The Extended Window Patient

Presentation: 68-year-old woman, last known well 14 hours ago (wake-up stroke). Found at 7 AM with right hemiplegia and aphasia. NIHSS 18.

Imaging:

NCCT: ASPECTS 8
CTA: Left M1 occlusion, good collaterals (Tan 2)
CTP: Core 15 mL, Tmax >6s volume 95 mL, mismatch ratio 6.3

Analysis: Meets DEFUSE-3 criteria (core <70 mL, mismatch ratio >1.8, mismatch volume >15 mL, time <16 hours).

Management:

Proceed directly to thrombectomy
No IV alteplase (>4.5 hours)
Achieve TICI 3 recanalization
Post-procedure NIHSS 6
Start nicardipine drip for SBP 155 mmHg (target <140)
ICU admission with q1h neuro checks
24-hour CT: No hemorrhage → start aspirin 325 mg

Outcome: mRS 1 at 90 days

Pearl: Extended window patients with favorable imaging often achieve excellent outcomes—don't let the clock alone deter treatment.

Case 2: The Direct-to-Angio Suite

Presentation: EMS called to 55-year-old man with sudden left-sided weakness. LAMS score 4 (high probability LVO). EMS pre-notifies thrombectomy center.

Pre-hospital: BP 165/95, glucose 135, RACE score 7

Hospital course:

Angio suite team waiting on arrival
Brief focused exam: NIHSS 16, left hemiplegia, gaze deviation
Taken directly to angio suite
Portable CT/CTA performed in angio suite antechamber (2 minutes from arrival)
Right M1 occlusion confirmed
IV alteplase 0.9 mg/kg initiated during groin preparation
Groin puncture 22 minutes from hospital arrival
TICI 2c recanalization, 47 minutes first-pass to final angiogram
Post-procedure NIHSS 4

Key Success Factors:

Pre-hospital recognition and notification
Angio suite team activation before arrival
Parallel processing (imaging + preparation)
IV thrombolysis didn't delay thrombectomy
Door-to-puncture <30 minutes

Oyster: Patient initially classified as "right-sided weakness" by family. EMS recognized left hemiplegia. Emphasizes importance of trained pre-hospital stroke recognition.

Case 3: Post-Thrombectomy Hemorrhagic Transformation

Background: 72-year-old with left M1 occlusion, TICI 2b recanalization, baseline NIHSS 14, post-procedure NIHSS 8. Admitted to ICU on nicardipine drip (SBP 130s).

Hour 8 post-procedure: Nurse reports decreased responsiveness. BP 145/88.

Re-evaluation: NIHSS now 18. New right gaze preference, GCS 10 (down from 15).

Imaging: Stat NCCT shows large PH-2 hemorrhage in left basal ganglia/corona radiata with 8 mm midline shift.

Management:

Neurosurgery stat consult
Nicardipine discontinued; allow SBP 140-160
HOB 30 degrees
Mannitol 1 g/kg IV
Sodium goal 145-150 (hypertonic saline)
Hold antiplatelets
Serial imaging q6h

Outcome: Hemorrhage stabilized without surgery. Patient underwent aggressive rehabilitation, mRS 4 at 90 days.

Teaching Points:

PH-2 hemorrhage often occurs 6-24 hours post-procedure
Sudden decline warrants immediate imaging
BP liberalization paradoxically appropriate—need perfusion pressure
Not all hemorrhagic transformations require surgery
mRS 4 (moderately-severe disability) still preferable to mRS 5-6 (severely disabled/dead) without intervention

Controversies and Unsettled Questions

1. Thrombectomy Alone vs. IV Thrombolysis + Thrombectomy

The Debate: Asian trials (DIRECT-MT, SKIP) showed non-inferiority of thrombectomy alone; Western trials (DIRECT-SAFE) suggested benefit of combination.

Current Consensus (2025):

If no delay: Give IV thrombolysis
If delay anticipated: Proceed directly to thrombectomy
Patient preference matters: Discuss hemorrhage risk vs. potential benefit

What's Next: Ongoing trials (SWIFT-DIRECT, MR CLEAN-NO IV) may provide definitive answers.

2. General Anesthesia vs. Conscious Sedation

The Evidence:

Early observational studies suggested GA associated with worse outcomes
Randomized trials (SIESTA, AnStroke, GOLIATH) showed no difference or potential GA benefit
Current practice: Variable by institution

Practical Approach:

Conscious sedation preferred for cooperative patients
GA indicated for: Agitation, airway protection needs, posterior circulation strokes requiring prone positioning
Flexibility is key: Convert to GA if patient becomes uncooperative

3. Aspiration vs. Stent-Retriever vs. Combined

The Technology:

ADAPT (Aspiration): Direct aspiration first-pass technique
Stent-retriever: Solitaire, Trevo devices
Combined (Solumbra): Aspiration + stent-retriever simultaneously

Evidence: ASTER trial showed no superiority of either technique. Most operators now use "first-line contact aspiration" with stent-retriever as backup.

Pearl: Technique matters less than operator experience and first-pass effect. TICI 2c-3 on first pass predicts better outcomes than multiple passes achieving TICI 3.

4. Medium Vessel Occlusions: Where's the Line?

The Gray Zone: M2, M3, A2, P2 occlusions—too small for traditional devices, too large for IV thrombolysis alone.

Current Practice:

Highly variable
Smaller devices (3 mm aspiration catheters) expanding feasibility
Patient selection based on NIHSS severity and eloquent territory involvement

What's Needed: Randomized controlled trials (ESCAPE-MeVO ongoing)

The Road Ahead: Stroke Care in 2030

Predicted Developments:

Universal mobile stroke units in urban centers with >500K population
AI-automated patient selection reducing door-to-puncture times to <15 minutes
Neuroprotective agents finally achieving efficacy in human trials (after 1000+ failed attempts)
Extended thrombectomy indications to medium and potentially distal vessels
Intraprocedural neuroprotection during thrombectomy (hypothermia, pharmacologic)

Challenges Remaining:

Rural access disparities: Drip-and-ship models inadequate for 6-24 hour windows requiring perfusion imaging
Cost and equity: Thrombectomy costs $20,000-40,000 per procedure
Workflow optimization: Only 30% of eligible patients currently receive thrombectomy—system failures remain common

Summary: Key Takeaways for the Critical Care Physician

Imaging Selection Expands Eligibility: Don't let the clock alone determine treatment. Perfusion imaging identifies salvageable tissue up to 24 hours.
Direct-to-Angio Saves Time: For clear LVO patients, bypassing ED reduces door-to-puncture by 30+ minutes. Systems should support this workflow.
Blood Pressure is Critical: Post-thrombectomy BP management (SBP <140 mmHg for 24 hours if successful recanalization) is perhaps the most important modifiable factor preventing hemorrhagic transformation.
Anticipate Complications: Hemorrhagic transformation, cerebral edema, and aspiration are common. Proactive surveillance and prevention strategies improve outcomes.
Antiplatelet Timing Matters: Wait 24 hours post-IV thrombolysis before starting antiplatelets. Delay anticoagulation 3-14 days based on infarct size.
Temperature, Glucose, BP: These three parameters are often suboptimal yet disproportionately impact outcomes. Scheduled interventions (not PRN) ensure compliance.
Multidisciplinary Care Wins: Stroke outcomes improve with specialized units, experienced teams, and protocol-driven care. Invest in systems, not just individual expertise.

Final Thoughts

The transformation from thrombolysis-centered care to thrombectomy-dominant treatment represents one of modern medicine's most dramatic success stories. Interventions once thought impossible—recanalization of major cerebral vessels 24 hours after onset—are now standard practice. Yet with this power comes responsibility: ensuring equitable access, optimizing every minute of the care pathway, and managing the complex post-procedure period with the vigilance it demands.

For the critical care physician, stroke has evolved from a "neurologist's disease" to a truly multidisciplinary emergency requiring expertise in resuscitation, advanced imaging interpretation, hemodynamic management, and anticipation of life-threatening complications. Mastery of these principles transforms outcomes—the difference between a patient returning to independent life versus permanent disability.

As we stand in 2025, the code stroke overhaul is not complete—it is ongoing. Every protocol refinement, every minute saved, every complication prevented contributes to the ultimate goal: minimizing the devastating impact of stroke on our patients and their families. The tools are now in our hands. The question is: Are our systems optimized to deliver them?

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Friday, November 7, 2025