Endovascular Approaches to Acute Stroke, Part 1: Drugs, Devices, and Data

Abstract

SUMMARY:Despite years of research and pioneering clinical work, stroke remains a massive public health concern. Since 1996, we have lived in the era of US Food and Drug AdministrationϪapproved intravenous (IV) recombinant tissue plasminogen activator (rtPA). This treatment, despite its promise, continues to exhibit its limitations. Endovascular therapy has several theoretic advantages over IV rtPA, including site specificity, longer treatment windows, and higher recanalization rates. In this article, we will review the various pharmacologic strategies for acute stroke treatment, providing both a historic context and the state of the art. The drugs will be classified on the basis of their theoretic rationale for therapy. Next, we will review the various devices and strategies for mechanical revascularization with an aim toward comprehensiveness. These range from wire disruption of thrombus to preclinical trials for novel mechanical solutions. This first installment of this 2-part series will end with an analysis of retrograde reperfusion techniques.

Endovascular stroke treatment now and then—procedural and clinical effectiveness and safety of different mechanical thrombectomy techniques over time

“…The most essential development was the shift from sole intra-arterial thrombolysis to endovascular thrombectomy with dedicated thrombectomy devices (7,8). Our results support the hypothesis that EST with stentretrievers as first-choice devices improves procedural times.…”

“…While intra-arterial thrombolysis and mechanical thrombus fragmentation have been the sole interventional treatment options for a long time, the advent of endovascular thrombectomy devices in the early years of the new millennium was a milestone in EST (7,8). After the introduction of various devices such as the MERCI ® device (Concentric, Mountain View, USA), the Phenox clot retriever (Phenox, Bochum, Germany), or the Penumbra ® system (Penumbra, Alameda, USA), stent-retrievers such as the Solitaire TM device (ev3, Irvine, USA) emerged as the most effective thrombectomy devices (7)(8)(9)(10). While complete recanalization was also possible with the first endovascular thrombectomy devices, recanalization could be very time-consuming and was not always associated with favorable clinical outcome (11).…”

Self-Expanding Stent for Recanalization of Acute Embolic or Dissecting Intracranial Artery Occlusion

“…[4][5][6][7] This strategy of using a recapturable self-expanding stent may provide immediate recanalization of an acutely occluded artery. This early restoration of flow may more quickly promote endogenous or pharmacologic thrombolysis.…”

The Impact of Thromboemboli Histology on the Performance of a Mechanical Thrombectomy Device

“…[1][2][3][4][5][6][7] However, frequently 2 angiographically identical occluded vessels in patients with acute stroke will respond differently to MT for reasons that are not angiographically evident. One hypothesis is that the performance of the MT device is influenced by the histologic characteristics of thromboembolus (eg, fibrin/cellular component), but current image technology cannot differentiate thromboemboli of varying histologic characteristics.…”