Guidelines for Post-thrombectomy Management of ELVO Patients


Patients with emergent large vessel occlusions (ELVO) benefit from mechanical thrombectomy and appropriate postoperative care is necessary to optimize outcomes.  Recent SNIS guidelines covered post-thrombectomy care, ischemic penumbra, therapeutic hypertension, complication management, malignant cerebral edema, access site complications, and rehabilitation.  Post-operative care should be performed in a dedicated stroke unit with coordinated multidisciplinary care.  Patients with incomplete recanalization after thrombectomy require hemodynamic support to sustain ischemic penumbra for >24 hours. Additionally, reperfusion injury and hemorrhagic transformation of infarcts lead to worse functional outcome; therefore, judicious postop imaging is needed.  Blood pressure goals should balance penumbra perfusion against risk for reperfusion injury and hemorrhage.  MAPs 10-20% above baseline (<SBP 185mmHg) support ischemic penumbra, but lower SBP is necessary following hemorrhage (140-160mmHg). IV tPA should be reversed after hemorrhages.  Malignant cerebral edema occurs after large completed infarcts and requires interventions to reduce mortality and morbidity. Arterial access sites need to be closely monitored and managed for complications.  Finally, patients need timely assessment for inpatient rehabilitation placement.  90-day functional outcome assessments should be performed as standard follow-up.  This guideline emphasizes the most important post-thrombectomy factors for improving functional outcome in ELVO patients.  

Michelle J. Smith, MD
Philadelphia, PA