Indications for Mechanical Thrombectomy for Acute Ischemic Stroke

Abstract

Purpose of the ReviewThis article reviews recent breakthroughs in the treatment of acute ischemic stroke, mainly focusing on the evolution of endovascular thrombectomy, its impact on guidelines, and the need for and implications of next-generation randomized controlled trials.Recent FindingsEndovascular thrombectomy is a powerful tool to treat large vessel occlusion strokes and multiple trials over the past 5 years have established its safety and efficacy in the treatment of anterior circulation large vessel occlusion strokes up to 24 hours from stroke onset.SummaryIn 2015, multiple landmark trials (MR CLEAN, ESCAPE, SWIFT PRIME, REVASCAT, and EXTEND IA) established the superiority of endovascular thrombectomy over medical management for the treatment of anterior circulation large vessel occlusion strokes. Endovascular thrombectomy has a strong treatment effect with a number needed to treat ranging from 3 to 10. These trials selected patients based on occlusion location (proximal anterior occlusion: internal carotid or middle cerebral artery), time from stroke onset (early window: up to 6–12 hours), and acceptable infarct burden (Alberta Stroke Program Early CT Score [ASPECTS] ≥6 or infarct volume <50 mL). In 2017, the DAWN and DEFUSE-3 trials successfully extended the time window up to 24 hours in appropriately selected patients. Societal and national thrombectomy guidelines have incorporated these findings and offer Class 1A recommendation to a subset of well-selected patients. Thrombectomy ineligible stroke subpopulations are being studied in ongoing randomized controlled trials. These trials, built on encouraging data from pooled analysis of early trials (HERMES collaboration) and emerging retrospective data, are studying large vessel occlusion strokes with mild deficits (National Institutes of Health Stroke Scale <6) and large infarct burden (core volume >70 mL).

Functional outcome prediction of ischemic stroke patients with atrial fibrillation accepting post-acute care training

“…However, there has been less focus on the sub-acute and chronic phases of rehabilitative training programs that have been designed for the speedy recovery of the neurological and daily life activities of patients. Reviewing the current literature, it is possible to notice how the inclusion and exclusion criteria of aggressive intervention therapy namely, intravenous thrombolytic and/or intra-arterial (IA) thrombectomy treatments (3)(4)(5), and the cardiogenic origin induced index stroke episode have not been thoroughly investigated, as well as the long-term outcome for this type of stroke patients. For most patients with stroke and…”

Thrombectomy in large vessel occlusion stroke—Does age matter?

“…Successful EVT leads to significantly improved clinical outcomes for emergent LVO stroke and several studies have demonstrated its efficacy beyond the strict RCT inclusion criteria. 11 , 12 However, in the context of limited resources, substantial procedural costs, globally increasing stroke cases, and the socioeconomic costs of healthcare selecting those patients likely to benefit from EVT is of increasing importance. In the setting of patient selection and prognostication for good EVT outcome, age is an important variable.…”

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

“…IVT is an established part of stroke reperfusion therapy that, in the setting of large vessel occlusions (LVO), should be combined with mechanical reperfusion [10][11][12][13][14][15][16]. There is some evidence in intracranial LVO strokes that IVT administration prior to emergency mechanical reperfusion (EMR) may be associated with increased early recanalization rate [14][15][16]; but this may be less applicable to AIS-CA due to the typically large thrombus burden in AIS-CA [6,9,17]. Some authors suggest that the bleeding risk with mechanical recanalization may be increased if IVT precedes mechanical thrombectomy (MT) [13,18].…”

“…Pivotal trials of mechanical intervention in AIS have been focused on intracranial LVO; patients with AIS due to extracranial carotid artery (CA) occlusion were routinely excluded or severely underrepresented [ 17 , 19 , 20 ]. As a result of trials, MT of the intracranial CA occlusion causing AIS is today recommended in all eligible patients (class I, level of evidence A recommendation) [ 12 , 17 ]. This contrasts with the data gap regarding EMR of causative occlusions of the extracranial internal CA, including tandem lesions.…”

“…Recent technological advances allow thrombus extraction using aspiration and/or stentrievers, with a high recanalization rate [ 11 , 17 ], from the extracranial internal CA (similarly to the intracranial segments of internal CA [ 24 ]), as well as a full reconstruction of the CA lumen with lesion sequestration [ 25 ]. However, data on the implementation of these new technologies in acute stroke are scarce [ 24 ].…”