Intravenous thrombolysis and intra‐arterial interventions in acute ischemic stroke: I talian S troke O rganisation ( ISO )‐ SPREAD guidelines

i.v. Thrombolysis (IVT) is the most important achievement of the last 20 years in the field of ischemic stroke management. In Italy, the evidence that stroke units were effective per se in improving stroke outcome was not sufficient to favor their implementation. Only the approval of IVT boosted the activation of stroke units, which are now 170 centers widespread over the country. The numbers of treatments, however, are still limited, amounting in 2014 to approximately 4200 out of the 10 000 which should theoretically be performed each year. Too strict exclusion criteria and/or their too restrictive interpretation are two of the main causes of this substantial undertreatment. Hence, a critical reappraisal of these criteria was necessary. On the other hand, recent evidences on the potentialities of intra-arterial interventions made it mandatory to better define the role of these techniques in the chain of treatments for acute ischemic stroke. A panel of vascular neurologists (D. T., D. I., A. C., E. A., P. C., A. Z.) and of interventional neuro-radiologists (S. M., S. V., M. B.) collected the data through a systematic review of the available literature, searching electronic databases including PubMed, EMBase, OVID, and Cochrane Library, up to May 2015. Reference lists of the selected articles were also scrutinized. Each panelist was assigned individual sections, then the panel assessed the complete guidelines. Recommendations were formulated by integrating the principles of the Scottish Intercollegiate Guideline Network with the statistical considerations suggested by the Centre for EvidenceBased Medicine methodology (Table 1). When literature data and practice experience data were not available or not considered to be sufficient, no specific recommendation was made. Consensus was reached during face-to-face discussions. In case of disagreement, a majority decision was taken. Recommendations were then revised by a larger group of experts pertaining to the fields of trial methodology, vascular neurology, cardiology, emergency medicine, neurosurgery, vascular surgery, neuro-radiology, and rehabilitation (see Appendix S1), which in particular checked for the congruence between the grading and the source data.