The following are 10 points to remember about this focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment:

1. Patients eligible for intravenous (IV) recombinant tissue-type plasminogen activator (r-tPA) should receive IV r-tPA even if endovascular treatments are being considered. (Class I; Level of Evidence A).
2. Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation):
   • Prestroke modified Rankin scale score of 0-1,
   • Acute ischemic stroke receiving IV r-tPA within 4.5 hours of onset according to guidelines from professional medical societies,
   • Causative occlusion of the internal carotid artery or proximal middle cerebral artery (M1),
   • Age ≥18 years,
   • National Institutes of Health Stroke Scale (NIHSS) score of ≥6,
   • Alberta Stroke Program Early CT Score (ASPECTS) of ≥6, and
   • Treatment can be initiated (groin puncture) within 6 hours of symptom onset.
3. In carefully selected patients with anterior circulation occlusion who have contraindications to IV r-tPA, endovascular therapy with stent retrievers completed within 6 hours of stroke onset is reasonable.
4. As with IV r-tPA, reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better clinical outcomes. To ensure benefit, reperfusion to Thrombolysis In Cerebral Infarction (TICI) grade 2b/3 should be achieved as early as possible and within 6 hours of stroke onset (Class I; Level of Evidence B-R).
5. Emergency imaging of the brain is recommended before initiating any specific treatment for acute stroke (Class I; Level of Evidence A). In most instances, nonenhanced CT will provide the necessary information to make decisions about emergency management.
6. If endovascular therapy is contemplated, a noninvasive intracranial vascular study is strongly recommended during the initial imaging evaluation of the acute stroke patient, but should not delay IV r-tPA if indicated. For patients who qualify for IV r-tPA according to guidelines from professional medical societies, initiating IV rtPA before noninvasive vascular imaging is recommended for patients who have not had noninvasive vascular imaging as part of their initial imaging assessment for stroke. Noninvasive intracranial vascular imaging should then be obtained as quickly as possible (Class I; Level of Evidence A). (New recommendation).
7. Patients should be transported rapidly to the closest available certified primary stroke center or comprehensive stroke center or, if no such centers exist, the most appropriate institution that provides emergency stroke care, as described in the 2013 guidelines (Class I; Level of Evidence A). In some instances, this may involve air medical transport and hospital bypass.
8. Regional systems of stroke care should be developed. These should consist of: (a) Healthcare facilities that provide initial emergency care including administration of IV r-tPA, including primary stroke centers, comprehensive stroke centers, and other facilities. (b) Centers capable of performing endovascular stroke treatment with comprehensive periprocedural care, including comprehensive stroke centers and other healthcare facilities, to which rapid transport can be arranged when appropriate (Class I; Level of Evidence A).
9. Endovascular therapy requires the patient to be at an experienced stroke center with rapid access to cerebral angiography and qualified neurointerventionalists. Systems should be designed, executed, and monitored to emphasize expeditious assessment and treatment.
10. Outcomes on all patients should be tracked. Facilities are encouraged to define criteria that can be used to credential individuals who can perform safe and timely intra-arterial revascularization procedures (Class I; Level of Evidence E).

Keywords: Carotid Artery, Internal, Cerebral Angiography, Cerebral Infarction, Emergency Medical Services, Endovascular Procedures, Middle Cerebral Artery, Punctures, Reperfusion, Societies, Medical, Stents, Stroke, Tissue Plasminogen Activator

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