NICE - thrombectomy in acute stroke

Last edited 06/2019 and last reviewed 10/2022

Brain imaging for the early assessment of people with suspected acute stroke

• if thrombectomy might be indicated, perform imaging with CT contrast angiography following initial non-enhanced CT. Add CT perfusion imaging (or MR equivalent) if thrombectomy might be indicated beyond 6 hours of symptom onset.

Thrombectomy for people with acute ischaemic stroke

Thrombectomy should be offered as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if not contraindicated and within the licensed time window), to people who have:

• acute ischaemic stroke and
• confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
• taking into account the factors*

Thrombectomy should be offered as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):

• who have acute ischaemic stroke and
• confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
• taking into account the factors*

Consider thrombectomy together with intravenous thrombolysis (where not contraindicated and within the licensed time window) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes):

• who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and
• if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
• taking into account the factors*

* factors to consider if possible thrombectomy

• take into account the person's overall clinical status and the extent of established infarction on initial brain imaging to inform decisions about thrombectomy. Select people who have:
  • a pre-stroke functional status of less than 3 on the modified Rankin scale and
  • a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS)

Reference:

• NICE (May 2019).Stroke and transient ischaemic attack in over 16s: diagnosis and initial management