Endovascular treatment of acute ischemic stroke

Jason Carroll MD (Dr. Carroll of Columbia University Medical Center has no relevant financial relationships to disclose.)
Sean D Lavine MD (Dr. Lavine of Columbia University Medical Center has no relevant financial relationships to disclose.)
Philip M Meyers MD (Dr. Meyers of the Neurological Institute of New York has no relevant financial relationships to disclose.)
Steven R Levine MD, editor. (Dr. Levine of the SUNY Health Science Center at Brooklyn has received honorariums from Genentech for service on a scientific advisory committee and a research grant from Genentech as a principal investigator.)
Originally released August 27, 2011; last updated February 21, 2017; expires February 21, 2020

This article includes discussion of endovascular treatment of acute ischemic stroke, mechanical thrombectomy for the treatment of acute ischemic stroke caused by large vessel occlusion of the anterior circulation, intraarterial therapy for the treatment of acute ischemic stroke caused by large vessel occlusion of the anterior circulation, and endovascular cerebral recanalization procedures. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Powerful new data from multiple randomized-controlled trials published in 2015 proved that mechanical thrombectomy with stent retrievers is superior to standard medical care in the treatment of carefully selected patients with acute ischemic strokes caused by large vessel occlusion in the proximal anterior circulation.

Acute ischemic stroke affects nearly 800,000 patients in the United States annually and is 1 of the leading causes of morbidity and mortality (Benjamin et al 2017). It is estimated that an intracranial large vessel occlusion, mostly commonly involving the proximal middle cerebral artery or intracranial internal carotid artery, occurs in approximately 25% to 50% of acute ischemic strokes (Smith et al 2009). Until recently, the only proven therapy for acute ischemic stroke was the administration of intravenous recombinant tissue plasminogen activator (IV-rtPA) within 4.5 hours of symptom onset (National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group 1995; Hacke et al 2008; Emberson et al 2014). Although timely administration of IV-rtPA improves functional independence at 90 days, it does not reduce mortality versus placebo (National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group 1995; Hacke et al 2008; Emberson et al 2014). Additionally, recanalization rates of acute ischemic stroke with large vessel occlusion treated with IV-rtPA remain extremely low (Bhatia et al 2010; Heldner 2013; Benjamin et al 2017). This is an important concept because large vessel occlusion recanalization rates are closely associated with good outcomes and reduced mortality (Bhatia et al 2010; Gonzalez et al 2013; Benjamin et al 2017). Furthermore, several studies have demonstrated a link between failed IV-rtPA recanalization and clot burden, suggesting there is a limit to the efficacy of IV-rtPA in the setting of large vessel occlusion (Bhatia et al 2010; Wanklyn et al 2014; Benjamin et al 2017). The limitations of IV-rtPA in the setting of large vessel occlusion have led to the emergence and rapid evolution of intraarterial therapies for the treatment of acute ischemic stroke.

Key points

 

• Acute ischemic strokes are 1 of the leading causes of morbidity and mortality in the United States and worldwide.

 

• Until recently, the only FDA-approved treatment for acute ischemic strokes was intravenous rtPA given within 4.5 hours of stroke onset.

 

• Intraarterial therapy of acute ischemic strokes has rapidly evolved over the past decade.

 

• New mechanical thrombectomy devices, known as stent retrievers, have improved recanalization rates of patients with acute ischemic strokes caused by intracranial large vessel occlusion.

 

• Five randomized, controlled trials published in 2015 demonstrated the efficacy of mechanical thrombectomy over standard medical care in the treatment of carefully selected acute ischemic stroke patients with large vessel occlusions in the anterior circulation.

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