Contraindications to Endovascular Treatment in Acute Ischemic Stroke: Where Evidence Ends and Structured Reasoning Begins — Therapeutic Advances in Neurological Disorders (SAGE), in press, 2026. Apostolos Safouris (first author), Georgios Tsivgoulis (corresponding author) and colleagues; fourteen authors in all. The full author list, the citation and the link will appear here the day the DOI is live.
Why the limits are where judgment lives
Every indication has an edge, and the edge is where the work is. Fifteen years of randomised trials have told us with increasing precision whom to treat: the occlusions, the windows, the cores, the severities inside which thrombectomy is one of the most effective interventions in medicine. They have said much less about the patient standing just outside those lines — older, frailer, milder, later, more distal, more posterior than the enrolment criteria allowed. That patient is not rare. She is the three-in-the-morning phone call.
A contraindication is usually read as a property of the patient. It is more honest to read it as the boundary of an evidence envelope: the point where the trials stopped enrolling, not necessarily the point where benefit stops. The two are routinely confused, and the confusion cuts both ways — treating on hope where the data say harm, and withholding on habit where the data say nothing at all. Absence of evidence is not evidence of harm; neither is it licence.
The review takes that boundary seriously. Its territory is the gray zones where the randomised envelopes end — minor deficits with a proximal occlusion, the large ischaemic core, frailty and biological reserve, the distal and medium vessels, the basilar artery, and the exclusions trials carried forward for historical rather than biological reasons — and asks what structured reasoning owes a patient there, once the guidelines have gone quiet. Not a verdict for every case; a discipline for reaching one.
This is the same territory this site argues on Where the answers come apart: the decisions worth supporting are precisely the ones the evidence does not settle.
The published record behind it
- Safouris A, et al. Overview of systematic reviews comparing endovascular to best medical treatment for large-vessel occlusion acute ischaemic stroke: an umbrella review. Ther Adv Neurol Disord 2024. PMID 38685935 · doi:10.1177/17562864241246938.
- Safouris A, et al. Medical Management Versus Endovascular Treatment for Large-Vessel Occlusion Anterior Circulation Stroke With Low NIHSS. Stroke 2023. PMID 37526011 · doi:10.1161/STROKEAHA.123.043937.
- Palaiodimou L, et al. Endovascular Treatment in Acute Ischemic Stroke Due to Occlusion of Medium or Distal Vessels: A Systematic Review and Meta-Analysis. Neurology 2025. PMID 40825162 · doi:10.1212/WNL.0000000000214015.
The gray zones, as they arrive at 3am
The cases where this matters are concrete. The case bank holds them in the register in which they arrive — fictional spoken referrals, model-generated, no real patients — including the four that walk straight into this review's territory.
Break the demo — send a case
For stroke physicians and vascular neurologists only. This is not a route for personal medical questions; if you are a patient or a relative, do not use this address. The demo does not run anonymously, and it is not a clinical service. Every case is reviewed and approved by the administrator before it runs; responses may take several days. Never use this for a live clinical decision — for acute stroke, follow your local pathway.
Your case must contain no images and no patient-identifying data, and it must be retrospective — not an active patient awaiting a decision. A case may appear on this site anonymously, as a constructed teaching case; you are named only if you ask to be.