| Reworded | IA MT is strongly recommended for patients with AIS within 6 hours of onset and meet the following criteria: (1) pre-stroke mRS score of 0–1; (2) AIS caused by occlusion of the distal internal carotid artery (ICA) or MCA M1 segment; (3) age ≥18 years old; (4) NIHSS score ≥6; (5) ASPECTS ≥6. | I | A |
| New recommendation | For patients with AIS with anterior circulation LVO and a large core infarct within 24 hours of onset and who meet the inclusion criteria of the RESCUE-Japan LIMIT, ANGEL-ASPECT and SELECT 2 trials, IA MT is recommended. | I | A |
| Three RCTs (RESCUE-Japan LIMIT, ANGEL-ASPECT and SELECT 2) have demonstrated that IA MT is superior to medical management (MM) in treating patients with AIS with a large core infarction from an anterior circulation LVO.82–84 However, the imaging modality of the baseline large infarcts was different among the three trials. The RESCUE-Japan LIMIT trial enrolled patients who had ICA or M1 occlusions with an ASPECTS between 3 and 5 by DWI or NCCT (most DWI) and within 6 hours from onset to randomisation or no signal change in the initial image on FLAIR with ASPECTS 3–5 within 6–24 hours from the onset to randomisation.82 The ANGEL-ASPECT trial enrolled patients with AIS within 24 hours of onset with an ASPECTS between 3 and 5 on NCCT or 0–2 on NCCT with infarct-core volume between 70 and 100 mL.83 The SELECT 2 trial enrolled patients with a large infarct and the ASPECTS between 3 and 5 on NCCT or infarct-core volume >50 mL.84
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| Reworded | For patients with occlusion in the anterior cerebral artery or posterior cerebral artery, IA MT may be considered within 6 hours of symptom onset. | IIb | C |
| Reworded | For patients with occlusion in the cervical ICA or MCA M1 segment, and a pre-stroke mRS score >1, or NIHSS score <6, the use of stent-retriever IA MT may be considered within 6 hours of symptom onset (time of femoral artery puncture). | IIb | B |
| Reworded | For patients with AIS with an anterior circulation LVO within 6–16 hours of last known normal, IA MT is strongly recommended when they meet the inclusion criteria of the DAWN or the DEFUSE 3 study. | I | A |
| Reworded | For patients with AIS with an anterior circulation LVO within 16–24 hours of the last known normal, IA MT is recommended when they meet the inclusion criteria of the DAWN study. | IIa | B |
| New recommendation | For patients with acute BAO within 6 hours of onset who meet the inclusion criteria of the ATTENTION trial, IA MT is recommended. | IIb | B |
| Patients with acute BAO within 6–12 hours of onset are recommended for IA MT when they meet the inclusion criteria of the ATTENTION or BAOCHE trials. | IIa | A |
| Patients with acute BAO within 12–24 hours of onset are recommended for MT when they meet the inclusion criteria of the BAOCHE trial. | IIa | B |
| Among the BEST, BASICS, ATTENTION and BAOCHE trials that treated BAO,4 5 85 86 the BEST (42% vs 32%) and BASICS (44.2% vs 37.7%) trials did not find the superiority of IA MT to MM in patients with acute BAO within 8 hours or 6 hours of onset.85 86 The ATTENTION (46% vs 23%) and BAOCHE (46% vs 24%) trials found that IA MT is superior to MM in patients with acute BAO within 12 hours or 6–24 hours of onset.4 5
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| New recommendation | During IA MT, IA thrombolysis with rt-PA at a dose of 0.225 mg/kg can be performed in patients with a modified Thrombolysis in Cerebral Infarction 2b50 recanalisation even though these patients may have received intravenous thrombolysis before IA MT. | IIa | B |
| The CHOICE study explored whether adjuvant IA rt-PA can improve the clinical outcomes of patients after successful IA MT recanalisation. They found that IA rt-PA can significantly increase the proportion of 90-day mRS 0–1 compared with placebo (59.0% vs 40.4%, p=0.047), without increasing the risk of sICH and reducing the 90-day all-cause mortality. However, the CHOICE study was terminated early due to slow enrolment and drug supply problems caused by the COVID-19 pandemic. Large RCTs are still needed to verify their findings.87
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| Reworded | Patients with indications for IA MT should undergo treatment as soon as possible. When meeting the criteria for intravenous thrombolysis, intravenous thrombolysis should be initiated first while simultaneously considering bridging to IA MT. | I | A |
| Reworded | For patients with contraindications to intravenous thrombolysis, it is recommended considering direct IA MT as the treatment option for eligible patients with LVO. | IIa | A |
| Reworded | For patients with occlusion in the MCA M2 or M3 segments, IA MT may be considered if the onset of symptoms is within 6 hours. | IIb | B |
| Reworded | The benefit of MT in patients with AIS with LVO beyond 24 hours of onset is uncertain. | IIb | C |