Mechanical thrombectomy checklist

About this checklist

Before: eligibility

• Last known well documented
• Disabling neurological deficit present
• NIHSS documented
• Premorbid mRS documented
• Large vessel occlusion confirmed
• No intracranial haemorrhage
• Salvageable tissue identified
• Thrombectomy decision confirmed by the consultant

Before: imaging review

Non-contrast CT

No intracerebral, subarachnoid or subdural haemorrhage. ASPECTS calculated and recorded.

CT angiography

Occlusion site identified — ICA terminus, M1, M2 or basilar. Collaterals assessed. Tandem lesion assessed. Aortic arch anatomy reviewed.

CT perfusion or MRI, if performed

Core infarct assessed, penumbra assessed, mismatch profile favourable.

Before: clinical preparation

• Consent obtained
• Patient identity confirmed
• Allergies documented
• Anticoagulant history documented
• Weight documented
• Nil per mouth status confirmed and time recorded
• Bloods reviewed — FBC, U&E, creatinine, INR, PTT, glucose
• Blood group and screen completed
• Two large-bore IV lines inserted, both functioning, gauges recorded

Before: monitoring, blood pressure and anaesthesia

• ECG monitoring attached
• Pulse oximetry attached
• Blood pressure monitoring attached
• Oxygen therapy if saturation below 94%
• If thrombolysis given: BP confirmed below 185/110 mmHg
• If no thrombolysis: BP acceptable for thrombectomy
• Current BP and any agent used recorded
• Anaesthesia informed and airway assessed
• Conscious sedation or general anaesthesia planned and documented

Before: angiography suite

• Imaging uploaded to the suite
• Procedure explained to patient and family
• Groins exposed and prepared
• Ultrasound available if required
• Equipment prepared — aspiration system, stent retriever, balloon guide catheter available
• Heparinised flush: concentration verified against local protocol, pressure bag functioning, continuous flush connected
• Procedural time out completed — correct patient, procedure and side; imaging reviewed; team brief done

After: procedural record

• Access site recorded — femoral, radial or other
• Device used recorded — aspiration, stent retriever, combined, balloon guide catheter
• Times recorded — arrival in suite, groin puncture, first pass, final pass, recanalisation, procedure end
• Reperfusion result graded on the TICI scale
• Number of passes documented
• Complications documented

After: access site and neurological assessment

• Haemostasis achieved — closure device used or manual compression performed
• No active bleeding
• Distal pulses present
• Groin soft, no haematoma
• Pre- and post-procedure NIHSS recorded
• Conscious level, motor examination, speech and cranial nerves documented

After: orders and handover

• Blood pressure targets documented — after successful reperfusion (TICI 2B–3) systolic is generally maintained below 180 mmHg per institutional protocol; after incomplete reperfusion, individualised targets documented and discussed
• Neurological observations commenced
• ICU or HDU admission arranged
• Follow-up CT requested
• Antithrombotic plan documented
• DVT prophylaxis considered
• IV fluids prescribed
• Neurology, ICU or HDU, and the stroke unit informed
• Family updated and consultant updated
• Procedure note completed and handover completed