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Acute stroke · published review

Where evidence ends and structured reasoning begins.

The limits of thrombectomy evidence, and the grey-zone cases encountered in acute stroke.

Contraindications to endovascular treatment in acute ischemic stroke

Our narrative review in Therapeutic Advances in Neurological Disorders examines the boundaries of the evidence for thrombectomy. Patients encountered in the acute phase do not always fit the populations enrolled in randomised trials.

The review considers six areas of uncertainty: large-vessel occlusion with mild symptoms, established large ischemic core, frailty and biological reserve, distal and medium vessel occlusion, basilar artery occlusion with mild symptoms, and exclusions inherited from the pivotal trials.

For these grey-zone cases, the unresolved question is how to bring the available evidence into an urgent, individual clinical decision.

Safouris A, et al. Contraindications to endovascular treatment in acute ischemic stroke: Where evidence ends and structured reasoning begins. Therapeutic Advances in Neurological Disorders. 2026;19. First published online 8 October 2026.

Read the open-access article

DOI: 10.1177/17562864261495272

Three worked examples, drawn

Where the trials stop and the patient begins.

Every randomised trial enrolled inside an envelope of age, severity, prestroke function, time and tissue. These three constructed cases sit at or beyond its edges, where the page’s evidence stops and the decision does not.

Constructed teaching cases — no patient is described. Nothing you choose here is stored or sent.

Case one — mild deficit, left M1, thrombolysis running

Age 46 years · NIHSS 4 · prestroke mRS not stated · last seen well 3.5 hours · ASPECTS 10, core 4 mL

  • This case
  • Envelope the case falls inside
  • Envelope the case falls outside
  • Guideline bracket
Case one — mild deficit, left M1, thrombolysis running plotted against the enrolment envelopes stated on the page.Case one - mild deficit, left M1, thrombolysis running. Age 46 years , NIHSS 4 , prestroke mRS not stated , last seen well 3.5 hours , ASPECTS 10, core 4 mL. On the Age (years) axis the page states no enrolment envelope for this case. On the NIHSS axis: MINOR-STROKE — NIHSS ≤ 5 (cohort, not a trial) — the case falls inside; ESO–ESMINT: enrol in trials, a guideline bracket; Pivotal EVT trials (record built above this score) — the case falls outside. On the Prestroke mRS axis the page states no enrolment envelope for this case. On the Time from last known well (h) axis the page states no enrolment envelope for this case. On the Ischaemic core / ASPECTS axis the page states no enrolment envelope for this case.No envelope stated on the page for this axis.405060708090Age (years)46 yearsMINOR-STROKE — NIHSS ≤ 5 (cohort, not a trial)ESO–ESMINT: enrol in trialsPivotal EVT trials (record built above this score)outside0510152025NIHSSNIHSS 4No envelope stated on the page for this axis.012345Prestroke mRSprestroke mRS not statedNo envelope stated on the page for this axis.06121824unknownTime from last knownwell (h)3.5 hNo envelope stated on the page for this axis.0246810Ischaemic core /ASPECTSASPECTS 10
Case one — mild deficit, left M1, thrombolysis running plotted against the enrolment envelopes stated on the page.Case one - mild deficit, left M1, thrombolysis running. Age 46 years , NIHSS 4 , prestroke mRS not stated , last seen well 3.5 hours , ASPECTS 10, core 4 mL. On the Age (years) axis the page states no enrolment envelope for this case. On the NIHSS axis: MINOR-STROKE — NIHSS ≤ 5 (cohort, not a trial) — the case falls inside; ESO–ESMINT: enrol in trials, a guideline bracket; Pivotal EVT trials (record built above this score) — the case falls outside. On the Prestroke mRS axis the page states no enrolment envelope for this case. On the Time from last known well (h) axis the page states no enrolment envelope for this case. On the Ischaemic core / ASPECTS axis the page states no enrolment envelope for this case.Age (years)No envelope stated on the page for this axis.40506070809046 yearsNIHSSMINOR-STROKE — NIHSS ≤ 5 (cohort, nota trial)ESO–ESMINT: enrol in trialsPivotal EVT trials (record built abovethis score)outside0510152025NIHSS 4Prestroke mRSNo envelope stated on the page for this axis.012345prestroke mRS not statedTime from last known well (h)No envelope stated on the page for this axis.06121824unknown3.5 hIschaemic core / ASPECTSNo envelope stated on the page for this axis.0246810ASPECTS 10
They are constructed teaching cases, written in the register in which a referral arrives; no patient is described here, and no patient material was used.

What this case shows is a population the pivotal trials were not built around — MR CLEAN's protocol admitted patients from NIHSS 2 with no severity restriction, yet the randomised record holds few patients like him — on which the observational data and the one randomised signal point in opposite directions.

ASPECTS 10; core 4 mL.

Read the published review