1.Indications

Occlusion: Proximal LVO (ICA, M1). NIHSS: ≥6. ASPECTS: 3-10 (0-6 h) or ≥6 (6-24 h). Pre-stroke: mRS 0–1. Time: 0–24 h from LKW.

2.Selection by Time Window

Early Window (0–6 h)

NCCT ASPECTS 3–10 (COR 1, LOE A; with NIHSS ≥6 and prestroke mRS 0–1). SELECT2 and ANGEL-ASPECT establish benefit in the large-core subset (ASPECTS 3–5 or core >50 ml).[+]

Late Window (6–24 h)

NCCT ASPECTS ≥6 (COR 1, LOE A; NIHSS ≥6, prestroke mRS 0–1), or 3–5 in selected patients (age <80, no significant mass effect). Perfusion mismatch on CTP or MRI (DAWN, DEFUSE-3) is one qualifying path.[+]

3.Posterior Circulation and Distal Occlusions

Basilar: EVT up to 24 h (ATTENTION, BAOCHE). Distal/MeVO: For proximal nondominant/codominant M2, distal MCA, ACA, or PCA occlusion, EVT should not be used routinely (COR 3: No Benefit, LOE A).[+]

4.Procedural Management

Bridging: IV tPA or TNK if eligible. Do not delay transport to angio for lytic effect.[+]

Anesthesia: Conscious sedation preferred; GETA if airway or agitation.[+]

BP: Avoid hypotension. SBP >140 mmHg to support collaterals until reperfusion.[+]

ICAD: If ICAD at clot site, may need angioplasty/stent and antiplatelet load.[+]

5.Complications

Reperfusion injury (hemorrhagic transformation: strict BP). Groin: hematoma, retroperitoneal bleed, limb ischemia. Vessel: dissection, perforation, embolization to new territory.[+]