Endovascular treatment of acute ischemic stroke
Updated on May 6, 2024 | 25 minutes reading
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Summary
Since 2015 when the first “positive” trials of intraarterial (IA) stroke technology (also commonly referred to as “endovascular therapy”) were announced, this new treatment has evolved tremendously and is currently the standard treatment of most patients with emergent large vessel occlusion (LVO). Devices such as stent retrievers and aspiration catheters allow higher recanalization rates than IA pharmacological thrombolysis and older, early thrombectomy devices could achieve. A variety of IA approaches is currently available, and selection of the optimal therapeutic intervention is based on clot location and size as well as the anatomy of the affected vessel. In this chapter, we review currently available treatment strategies for IA stroke and discuss relevant studies and their clinical significance and limitations.
Introduction
Stroke is the second most common cause of mortality worldwide and is estimated to be the number 1 cause of death and disability in developing countries 1. Intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rtPA) is an effective tool for the treatment of patients with acute ischemic stroke (AIS) and can be administered within the first 4.5...
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References
- Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy - ASPECTS Study Group - Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670-4. In this study, the ASPECTS grading scale was first introduced and described in detail.
- Huo X, Ma G, Tong X, Zhang X, Pan Y, Nguyen TN, Yuan G, Han H, Chen W, Wei M, Zhang J, Zhou Z, Yao X, Wang G, Song W, Cai X, Nan G, Li D, Wang AY, Ling W, Cai C, Wen C, Wang E, Zhang L, Jiang C, Liu Y, Liao G, Chen X, Li T, Liu S, Li J, Gao F, Ma N, Mo D, Song L, Sun X, Li X, Deng Y, Luo G, Lv M, He H, Liu A, Zhang J, Mu S, Liu L, Jing J, Nie X, Ding Z, Du W, Zhao X, Yang P, Liu L, Wang Y, Liebeskind DS, Pereira VM, Ren Z, Wang Y, Miao Z, Investigators A-A. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct. N Engl J Med. 2023;388(14):1272-83. A randomized trial from China showing the benefit of endovascualr thrombectomy in large core strokes with large vessel occlusion.
- Mokin M, Ansari SA, McTaggart RA, Bulsara KR, Goyal M, Chen M, Fraser JF, Society of NeuroInterventional S. Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg. 2019;11(3):215-20. These guideline from the Society of NeuroInterventional Surgery incorporated the data supporting thrombectomy in patients with stroke from large vessel occlusion.
- Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344-e418. These guidelines from the American Heart/American Stroke Association provide a comprehensive review on the diagnosis and management of patients with acute ischemic stroke, including those with large vessel occlusion.
- Sarraj A, Hassan AE, Abraham MG, Ortega-Gutierrez S, Kasner SE, Hussain MS, Chen M, Blackburn S, Sitton CW, Churilov L, Sundararajan S, Hu YC, Herial NA, Jabbour P, Gibson D, Wallace AN, Arenillas JF, Tsai JP, Budzik RF, Hicks WJ, Kozak O, Yan B, Cordato DJ, Manning NW, Parsons MW, Hanel RA, Aghaebrahim AN, Wu TY, Cardona-Portela P, Perez de la Ossa N, Schaafsma JD, Blasco J, Sangha N, Warach S, Gandhi CD, Kleinig TJ, Sahlein D, Elijovich L, Tekle W, Samaniego EA, Maali L, Abdulrazzak MA, Psychogios MN, Shuaib A, Pujara DK, Shaker F, Johns H, Sharma G, Yogendrakumar V, Ng FC, Rahbar MH, Cai C, Lavori P, Hamilton S, Nguyen T, Fifi JT, Davis S, Wechsler L, Pereira VM, Lansberg MG, Hill MD, Grotta JC, Ribo M, Campbell BC, Albers GW, Investigators S. Trial of Endovascular Thrombectomy for Large Ischemic Strokes. N Engl J Med. 2023;388(14):1259-71. Another randomized trial supporting thrombectomy of large core strokes using perfusion imaging for patient selection.
- Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, Marks MP, Prabhakaran S, Kallmes DF, Fitzsimmons BF, Mocco J, Wardlaw JM, Barnwell SL, Jovin TG, Linfante I, Siddiqui AH, Alexander MJ, Hirsch JA, Wintermark M, Albers G, Woo HH, Heck DV, Lev M, Aviv R, Hacke W, Warach S, Broderick J, Derdeyn CP, Furlan A, Nogueira RG, Yavagal DR, Goyal M, Demchuk AM, Bendszus M, Liebeskind DS. Cerebral Angiographic Revascularization Grading Collaborators, STIR Revascularization Working Group, STIR Thrombolysis in Cerebral Infarction Task Force - Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke. 2013;44(9):2650-63. This article reviews different angiographic revascularization scales for patients with stroke.
- Zaidat OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Dabus G, Malisch TW, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Nguyen TN, Taqi MA, Abraham MG, Yoo AJ, Janardhan V, Shaltoni H, Novakovic R, Abou-Chebl A, Chen PR, Britz GW, Sun CJ, Bansal V, Kaushal R, Nanda A, Nogueira RG. First Pass Effect: A New Measure for Stroke Thrombectomy Devices. Stroke. 2018;49(3):660-6. This was the first study that introduced first pass effect outcome as a new metric of thrombectomy success or failure.
- Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama a Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW, MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11-20. MR CLEAN was the first randoized trial showing the superiority of mechanical revascularization over medical management in stroke patients with large vessel occlusion.
- Al-Mufti F, Marden FA, Burkhardt JK, Raper D, Schirmer CM, Baker A, Chen PR, Bulsara KR, Narsinh KH, Amans MR, Cooper J, Yaghi S, Al-Kawaz M, Hetts SW, Standards S, Guidelines C, Directors SBo. Endovascular therapy for anterior circulation emergent large vessel occlusion stroke in patients with large ischemic cores: a report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg. 2024. An updated from the Society of NeuroInterventional Surgery on the role of thrombectomy in patients with large core strokes.