Clinical Pathways
Clinical Pathways
Large-vessel occlusion
Large-vessel occlusion

Large-vessel occlusion

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Action

  • Discuss with stroke team (Class I)
  • Consult with neurointerventionalist (Class I)
  • Evaluate eligibility for thrombectomy, incorporating perfusion imaging results, if performed (Class III)

Decision

Candidate for thrombectomy?

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Yes → Perform procedural intervention (Class III) and admit to ICU
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No → Admit to ICU

Background

Several case reports have been published indicating that the use of endovascular therapy for septic emboli may result in a favorable outcome. A literature review of 30 cases of patients with septic emboli from infective endocarditis who were treated with endovascular therapy described a decreased NIHSS, from 15 pretreatment to 2.5 posttreatment. However, the risk for ICH was 13.3%, and 90-day mortality was 23.3% in this higher-risk patient population. The patients described in case reports of endovascular therapy in the setting of infective endocarditis were commonly anticoagulated, and had a septic emboli to a middle cerebral artery vessel. Both stent retrievers and aspiration catheters have been described in this setting. No prospective trials have been conducted to determine the safety or efficacy of endovascular therapy for septic emboli; however, endovascular therapy may be an emerging treatment for patients who develop an ischemic stroke due to infective endocarditis and have limited acute therapeutic options. In the acute setting, early consultation with stroke and interventionalist teams should be prioritized to determine whether the patient is a candidate for thrombectomy, given limited treatment options in the ED setting.

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References
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