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Thrombectomy for Acute Ischemic Stroke: Recent Insights and Future Directions

  • Stroke (H Diener, Section Editor)
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Abstract

Purpose of Review

Mechanical thrombectomy has become the standard of care for acute ischemic stroke with proximal large vessel occlusions (LVO). This article reviews recent research relating to thrombectomy.

Recent Findings

Thrombectomy for anterior circulation stroke with proximal LVO was first shown to be highly efficacious within 6 h of stroke onset, but “late-window” trials have further demonstrated efficacy until 24-h postonset in select patients with salvageable tissue. However, the concept of “time is brain” remains critical. Thrombectomy trials have further stimulated worldwide efforts to develop systems of care for rapid treatment of eligible patients. Thrombectomy is cost-effective and likely to have long-term efficacy for both disability and mortality outcomes.

Summary

Thrombectomy is a highly efficacious acute stroke therapy. Enduring uncertainties include efficacy in patients with premorbid disability, posterior circulation, or more distal occlusions; use of bridging thrombolysis; and optimal techniques to achieve consistent revascularization and address tandem occlusions or stenoses.

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Abbreviations

ACA:

Anterior cerebral artery

AIS:

Acute ischemic stroke

AnStroke:

Anesthesia during stroke

ASPECTS:

Alberta Stroke Program Early CT Score

ASTER:

Contact Aspiration versus Stent Retriever for Successful Revascularization

AURORA:

Analysis of Pooled Data from Randomized Studies of Thrombectomy more than 6 hours After Last Known Well

BGC:

Balloon-guide catheter

BP:

Blood pressure

CAPTIVE:

Continuous aspiration prior to intracranial vascular embolectomy

COMPASS:

Comparison of direct aspiration versus stent retriever as a first approach

CS:

Conscious sedation

CSC:

Comprehensive stroke center

C-STAT:

Cincinnati Prehospital Stroke Severity Scale

CTA:

Computed Tomography Angiography

CTP:

CT perfusion

DAWN:

DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo

DEFUSE-3:

Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke-3

DWI:

Diffusion-weighted imaging

ESCAPE:

Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times

ESCAPE NA-1:

Extension of Stroke Care by Added neuroprotection to Endovascular treatment

EXTEND-IA:

Extending the Time for Thrombolysis in Emergency Neurological Deficits - Intra-Arterial

FIV, PIV:

Final infarct volume, posttreatment infarct volume

GA:

General anesthesia

GOLIATH:

General or Local Anesthesia in Intra-Arterial Therapy

HERMES:

Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials

ICA:

Internal carotid artery

ICER:

Incremental cost-effectiveness ratio

INT, ENT:

Infarct in a New Territory, Embolus to New Territory

LAMS:

Los Angeles Motor Scale

LSN:

Last-seen-normal

LVO:

Large vessel occlusion

MCA:

Middle cerebral artery

MR CLEAN:

Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands

MR PREDICTS:

Multivariable personalized intra-arterial treatment clinical decision tool for ischemic stroke

mRS:

Modified Rankin Scale

NIHSS:

National Institutes of Health Stroke Scale

NNT:

Number needed to treat

PISTE:

Pragmatic Ischaemic Thrombectomy Evaluation

PIV:

Posttreatment infarct volume

PROBE:

Prospective, randomized, and open-label, with blinded endpoint assessment

PSC:

Primary stroke center

QALY:

Quality-adjusted life-year

RACE:

Rapid Arterial Occlusion Evaluation

RCT:

Randomized controlled trial

REVASCAT:

Endovascular Revascularization with Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours

r-tPA:

Recombinant tissue plasminogen activator

SIESTA:

Sedation vs Intubation for Endovascular Stroke Treatment

SWIFT-DIRECT:

Solitaire With the Intention For Thrombectomy Plus Intravenous t-PA Versus Direct Solitaire Stent Retriever Thrombectomy in Acute Anterior Circulation Stroke

SWIFT-PRIME:

Solitaire FR With the Intention For Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke

THRACE:

Thrombectomie des artères cerebrales

TICI:

Thrombolysis in Cerebral Infarction

TNK:

Tenecteplase

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Authors and Affiliations

  1. Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada

    Aravind Ganesh & Mayank Goyal

  2. Department of Radiology, University of Calgary, Calgary, Canada

    Mayank Goyal

  3. Seaman Family MR Research Centre, Foothills Medical Centre, University of Calgary, 1403 29th St NW, Calgary, AB, T2N 2T9, Canada

    Mayank Goyal

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  1. Aravind Ganesh
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Aravind Ganesh declares no conflict of interest.

Mayank Goyal reports grants from Medtronic, personal fees from Stryker, Medtronic, Microvention, and from Cerenovus. Stryker provided an unrestricted research grant to University of Calgary for the UNMASK EVT study. In addition, Dr. Goyal has a patent Systems of Acute Stroke Diagnosis issued to GE Healthcare.

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This article does not contain any studies with animal subjects performed by any of the authors. All human participants in the studies referenced in the paper either provided informed consent (or assent via family members) for their participation, or were permitted to have a waiver of consent in the hyperacute treatment setting by the relevant regional ethics board.

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Ganesh, A., Goyal, M. Thrombectomy for Acute Ischemic Stroke: Recent Insights and Future Directions. Curr Neurol Neurosci Rep 18, 59 (2018). https://doi.org/10.1007/s11910-018-0869-8

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