Endovascular Thrombectomy & Large Vessel Occlusion

ABPN Neurocritical Care Study Guide Exam

Track your progress as you read

Finished sections get a check mark.

1 Chapter 1: Neurologic Examination & Coma Assessment in the ICU

Current Examination, Blueprint & Preparation Neurologic Examination in Critically Ill Patients Coma Evaluation & Consciousness Alterations Delirium & Toxic-Metabolic Encephalopathy in the ICU

2 Chapter 2: Cerebral Physiology & Intracranial Dynamics

Cerebral Blood Flow, Metabolism & Autoregulation Intracranial Pressure & Compliance Cerebral Edema & Herniation Syndromes

3 Chapter 3: Intracranial Hypertension & Cerebral Perfusion Management

Tiered ICP Management Protocols Hyperosmolar Therapy & Fluid Management Advanced & Refractory ICP Interventions

4 Chapter 4: Airway, Mechanical Ventilation & Pulmonary ICU Management

Emergency Airway Management & Neuro-Intubation Mechanical Ventilation Strategies in Acute Brain Injury Tracheostomy & Ventilator Weaning in Neurocritical Care Pulmonary Complications in the Neuro-ICU Obstructive Lung Disease, Pulmonary Hypertension & Bronchoscopy

5 Chapter 5: Hemodynamics, Shock & Cardiovascular Management

Hemodynamic Monitoring & Blood Pressure Targets Vasoactive Agents: Inotropes, Vasopressors & Antihypertensives Cardiac Complications of Brain Injury

6 Chapter 6: Neuropharmacology, Analgesia & Sedation

ICU Sedation & Analgesia Neuromuscular Blockade & Monitoring Propofol Infusion Syndrome & Drug Toxicities Antiseizure Drug Pharmacology in the ICU

7 Bleeding, Thrombosis & Hematologic Emergencies

Warfarin & Heparin Reversal Direct Oral Anticoagulant (DOAC) Reversal Antiplatelet Management & Platelet Dysfunction Venous Thromboembolism Prophylaxis & Management Transfusion, Coagulopathy, TMA & Cellular-Therapy Neurotoxicity

8 Chapter 8: Systemic ICU Care, Fluids, Electrolytes & Endocrine

Hyponatremia & Osmoregulation: SIADH vs Cerebral Salt Wasting Diabetes Insipidus, Hypernatremia & Endocrine Crises Critical Care Prophylaxis, Nutrition & Infection Prevention

9 Systemic Trauma & Environmental Injury

Polytrauma, Chest Injury & Abdominal Hemorrhage Burns, Electrical Injury & Hanging

10 Cardiac Emergencies & Mechanical Support

IABP, Ventricular Devices & ECMO Acute Coronary, Valvular, Rhythm & Aortic Emergencies

11 Kidney Injury, Acid–Base & Renal Replacement

Acute Kidney Injury & Renal Drug Clearance Acid–Base Disorders, Electrolytes & Renal Replacement

12 Systemic Infection & Endocrine Emergencies

Sepsis, Endocarditis & Antimicrobial Principles Thyroid, Adrenal & Dysglycemic Emergencies

13 Gastrointestinal & Hepatic Emergencies

Acute Abdomen, GI Bleeding & Abdominal Compartment Syndrome Acute Liver Failure, Cirrhosis & Hepatic Drug Effects

14 Chapter 9: Neuroimaging in the Neuro-ICU

Non-Contrast CT & CT Angiography CT Perfusion & Advanced Perfusion Imaging Magnetic Resonance Imaging in Critical Illness

15 Chapter 10: Electrophysiology & Neuromonitoring

Continuous EEG & ACNS Standardized Critical Care Terminology Invasive Neuromonitoring: ICP & External Ventricular Drains Multimodal Monitoring: PbtO2, Microdialysis & Transcranial Doppler

16 Angiography, Electrodiagnosis & CSF Analysis

Conventional Angiography & Cranial–Spinal Shunts EMG, Nerve Conduction & Acute Muscle Disease CSF Analysis: Infection, Inflammation & Hemorrhage

17 Chapter 11: Bedside Procedures, Ultrasound & Death by Neurologic Criteria

Critical Care Procedural Skills Critical Care Ultrasound & Echocardiography Determination of Death by Neurologic Criteria

18 Chapter 12: Acute Ischemic Stroke & Reperfusion Therapies

Acute Ischemic Stroke Management & Thrombolysis Endovascular Thrombectomy & Large Vessel Occlusion Malignant Hemispheric & Cerebellar Infarction

19 Chapter 13: Spontaneous Intracerebral Hemorrhage & Intraventricular Hemorrhage

Acute Intraparenchymal Hemorrhage Management Intraventricular Hemorrhage & Hydrocephalus Surgical Evacuation & Minimally Invasive Surgery in ICH

20 Chapter 14: Aneurysmal Subarachnoid Hemorrhage & Delayed Cerebral Ischemia

Aneurysmal Subarachnoid Hemorrhage: Acute Resuscitation & Securing Delayed Cerebral Ischemia & Cerebral Vasospasm Non-Aneurysmal Subarachnoid Hemorrhage & Vascular Malformations

21 Venous, Spinal & Traumatic Vascular Disease

Cerebral Venous Thrombosis & Spinal Cord Infarction Traumatic Dissection, Carotid–Cavernous Fistula & Penetrating Injury

22 Chapter 15: Traumatic Brain & Spinal Cord Injury

Severe Traumatic Brain Injury & Contusions Acute Traumatic Spinal Cord Injury & Neurogenic Shock Spine Trauma, Fractures & Cord Syndromes

23 Chapter 16: Status Epilepticus, Seizures & Neuromuscular Emergencies

Status Epilepticus: Convulsive & Non-Convulsive Refractory & Super-Refractory Status Epilepticus Acute Neuromuscular Respiratory Failure

24 Chapter 17: Post-Cardiac Arrest Care, CNS Infections & Encephalitis

Targeted Temperature Management & Post-Cardiac Arrest Care Post-Cardiac Arrest Neuroprognostication Acute CNS Infections, Encephalitis & Inflammatory Emergencies

25 Neuroinflammation & Neurooncology

Fulminant Demyelination & Autoimmune Encephalitis Brain, Spinal & Leptomeningeal Cancer Emergencies

26 Pregnancy, Transplantation & Pediatric Care

Pregnancy, Postpartum & Post-Transplant Neurologic Care Pediatric Neurocritical Care

27 Chapter 18: Neurosurgical & Perioperative Emergencies

Postoperative Neurosurgical Complications Device Complications: EVDs, Shunts & ICP Monitors Cerebral Hyperperfusion Syndrome & Post-Interventional Emergencies

28 Chapter 19: Ethics, Palliative Care & Organ Donation in the Neuro-ICU

Communication, Surrogate Decision-Making & Conflict Resolution Neuroprognostication Ethics, Withdrawal of Life Support & Palliative Care Organ Donation & Management of the Deceased Donor

Endovascular Thrombectomy & Large Vessel Occlusion

Key Takeaways Explain This Topic AI

HERMES reported an NNT of 2.6 for improvement by at least one mRS level, not an NNT of 2.6 for complete independence.

DAWN and DEFUSE-3 established selected late-window pathways, but their small-core criteria do not exhaust modern EVT eligibility.

Large-core trials support expanded treatment; TESLA did not meet its prespecified primary superiority threshold.

After EVT, avoid hypotension and do not routinely target SBP below 140 mm Hg even after complete reperfusion.

Last updated: October 2026

Recognize the Treatable Occlusion

Endovascular thrombectomy (EVT) mechanically removes thrombus from an accessible occluded artery using aspiration, a stent retriever, or selected combined techniques. The first decision is whether the clinical syndrome and vascular imaging indicate an occlusion for which treatment offers benefit. NIHSS, prestroke function, time, vessel location, tissue injury, collateral supply, and procedural feasibility all contribute. Do not equate every angiographic occlusion with identical eligibility.

Obtain rapid brain and vascular imaging and arrange neurointerventional assessment without unnecessary delay. Eligible IV thrombolysis should not be postponed merely to see whether EVT will occur or whether the patient improves. Conversely, being outside a conventional thrombolysis window does not by itself exclude EVT. Systems of care, transfer, and avoiding treatment delays remain important even when tissue imaging suggests salvageable brain.

Early and Extended Windows

The 2015 trials and HERMES patient-level meta-analysis established substantial disability reduction for selected proximal anterior-circulation occlusions. HERMES' reported number needed to treat of 2.6 concerned improvement by at least one modified Rankin Scale level. It should not be relabeled as the number needed for functional independence, which is a different endpoint.

DAWN studied selected patients 6–24 hours after last known well using a clinical-core mismatch. DEFUSE-3 studied selected patients 6–16 hours using a perfusion mismatch, with core below 70 mL, mismatch ratio at least 1.8, and mismatch volume at least 15 mL. These are historic trial-selection rules, not evidence that every patient who falls outside them must be denied treatment under current guidance.

For example, a core of 28 mL and hypoperfused volume of 105 mL give a ratio of 105/28 = 3.75 and mismatch volume 105−28 = 77 mL. Those values satisfy the DEFUSE-3 imaging mismatch thresholds, but vessel, time, clinical, and other eligibility requirements must still be assessed. A calculator result cannot replace interpretation of the source scans and vascular anatomy.

Large-Core and Basilar Occlusion

Randomized trials including SELECT2, ANGEL-ASPECT, RESCUE-Japan LIMIT, and other studies expanded evidence for selected large-core anterior-circulation strokes. Benefit is usually expressed as improved disability outcomes, not a guarantee of independence or normal recovery. Trials differ in ASPECTS, core volume, time, and inclusion criteria. TESLA did not meet its prespecified primary superiority threshold , so it should not be listed as an identically positive trial.

The 2026 guideline incorporates expanded EVT recommendations for selected large cores. Interpret ASPECTS with the full clinical and imaging context. A low score is no longer a universal exclusion, while extensive injury and other adverse features still matter. Automated perfusion estimates can overestimate or underestimate injury; a colored map does not prove histologically irreversible tissue in every voxel.

For basilar artery occlusion , ATTENTION and BAOCHE support treatment in selected patients. The 2026 guideline provides a strong recommendation for appropriate patients presenting within 24 hours with NIHSS at least 10. Posterior-circulation deficits may be inadequately represented by a low NIHSS, so urgent expert assessment remains necessary rather than relying on the score alone.

Reperfusion Grading and Anesthesia

• mTICI category General reperfusion description
• 0 No reperfusion
• 1 Minimal penetration without meaningful distal reperfusion
• 2a Less than half of the affected territory reperfused
• 2b At least half, but incomplete reperfusion
• 2c Near-complete reperfusion with small residual deficits
• 3 Complete reperfusion

Subdivisions and expanded grading systems add detail, so use the procedural report's definition. Reperfusion is an angiographic result; clinical recovery also depends on tissue injury, time, collaterals, and complications. A technically excellent result does not exclude infarction, hemorrhage, or later edema.

General anesthesia and procedural sedation are selected according to airway protection, cooperation, oxygenation, hemodynamics, and local expertise. Neither technique is universally superior for every patient. Prevent hypoxemia and avoid significant procedural hypotension, especially while tissue remains collateral-dependent. A controlled airway can help in an uncooperative or obtunded patient, but induction and transfer can also delay treatment or lower pressure if poorly coordinated.

Post-EVT Blood Pressure and Surveillance

The 2026 AHA/ASA guideline advises against intensive SBP lowering below 140 mm Hg after EVT , even with complete reperfusion. Trials of intensive lowering did not establish the benefit claimed in older physiologic arguments and identified harm in relevant settings. Do not use mTICI 3 as an automatic instruction to target SBP 120–130 or strictly below 140.

A usual upper limit around 180/105 mm Hg is used during and after EVT under the guideline, with individualized management of other emergencies, hypotension, and procedural circumstances. Maintain stable perfusion rather than selecting an arbitrary narrow target from an angiographic grade alone. Follow neurologic status, access-site complications, glucose, temperature, and appropriate imaging. New deficits warrant prompt assessment for hemorrhage, reocclusion, edema, seizures, or systemic deterioration.

Sources checked October 17, 2026: 2026 AHA/ASA summary , HERMES , and TESLA .