Stroke Guidelines

DEFUSE 3: 6-16 hours

Ischemic core volume of <70

-Age 18-85 years

-baseline NIHSS greater than or equal to 6

Endovascular femoral puncture between 6-16 hours

Pre-stroke mRS 0-2

Anticipated life expectancy of at least 6 months



-other serious, advanced, or terminal illness

-pre-existing neurological or psychiatric disease that would confound the evaluations


-contraindication to MRI/CRP contrast

-treated with tPA >4.5 hours after LKN

-known hereditary or acquired hemorrhagic diathesis, coagulation factor deficiency, oral anticoagulant with INR >3 (recent use of new oral anticoagulants ok if eGFR >30 ml/min)

-seizure at stroke onset if precludes obtaining accurate baseline NIHSS

-baseline glucose of <50 or >400

-baseline platelet count of <50, 000

-untreatable sustained hypertension SBP <185 or DBP >110

-presumed septic embolus, suspicion of bacterial endocarditis or cerebral vasculitis

-mechanical clot retrieval attempted prior to 6 hours from symptom onset


Imaging inclusion criteria:

-M1 MCA occlusion or ICA occlusion AND

-target mismatch profile on CT perfusion or MRI (RAPID)”

Ischemic core volume of <70 AND

Mismatch ration of >1.8 AND

Mismatch volume of > or equal to 15 ml

Or if only MRI, DWI lesion volume < 25 ml with M1 or CTA occlusion within 60 minutes

Neuroimaging exclusion criteria:

-ASPECTS <6 on noncontract HCT

-intracranial tumor (except for small meningioma)

-acute intracranial hemorrhage


-significant mass effect with midline shift

-evidence of ICA flow-limiting dissection or aortic dissection

-intracranial stent in the same territory that would preclude safe deployment/removal of device

-intracranial occlusions in multiple vascular territories





DAWN: 6-24 hours

Age 18 or greater

NIHSS 10 or greater

Prestroke modified rankin score <2

Anticipated life expectancy of at least 6 mo

<1/3 MCA territory involved via CT or MRI

Occlusion of either intracranial ICA and/or M1 via MRA or CTA


Clinical imaging mismatch via MRI-DWI or CTP-rCVF:

0–<21 cc core infarct; NIHSS ≥10 and age ≥80

0-<31 cc core infarct, NIHSS ≥10 and age < 80

31-<51 cc core infarct, NIHSS ≥20 and age< 80


General Exclusion criteria:

-severe head injury within 90 days

-rapid improvement to NIHSS <10 or vessel recanalization prior to randomization

-pre-existing neurological or psychiatric disease

-seizures at stroke onset

-blood glucose <50 or >400

-hemoglobin <7

-platelets <50,000

-sodium <130, potassium ❤ or >5

-renal failure

-hemorrhagic diathesis or INR >3 or PTT >3 times normal

-active or recent hemorrhage within 30 days

-severe allergy to contrast medium

-SBP >185 or diastolic BP >110

-pregnancy or lactation

-presumed septic embolus or suspicion of bacterial endocarditis

-prior treatment with thrombectomy intra-arterial therapies


Imaging exclusion criteria:

-intracranial hemorrhage

-flow limiting carotid dissection, high-grade stenosis, or complete cervical carotid occlusion

-excessive cervical vessel tortuosity

-suspected cerebral vasculitis

-suspected aortic dissection

-existing stent in the same vascular territory

-occlusions in different vascular territories

-significant mass effect/midline shift

-intracranial tumor