Endovascular treatment of acute ischemic stroke

Steven D Shapiro MD (

Dr. Shapiro of Columbia University Medical Center has no relevant financial relationships to disclose.

)
Charles B Beaman MD PhD (

Dr. Beaman of Columbia University Irving 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 Columbia University Medical Center has no relevant financial relationships to disclose.

)
Steven R Levine MD, editor. (

Dr. Levine of the SUNY Health Science Center at Brooklyn has no relevant financial relationships to disclose.

)
Originally released August 27, 2011; last updated July 21, 2020; expires July 21, 2023

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 stroke caused by large vessel occlusion in the proximal anterior circulation. Further studies in 2018 demonstrated the efficacy of mechanical thrombectomy in select patients up to 24 hours after onset of symptoms. It has been shown that direct aspiration can be used as an alternative to stent retrievers in acute ischemic stroke.

Acute ischemic stroke affects nearly 800,000 patients in the United States annually and is one of the leading causes of morbidity and mortality (Benjamin et al 2017). Intracranial large vessel occlusion, most commonly involving the proximal middle cerebral artery or intracranial internal carotid artery, occurs in approximately 30% of acute ischemic strokes (Lakomkin et al 2019). 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 stroke is a major cause of morbidity and mortality in the United States and worldwide.

 

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

 

• New mechanical thrombectomy techniques, including stent retrievers and direct aspiration, have greatly improved recanalization rates for patients with acute ischemic strokes caused by intracranial large vessel occlusion.

 

• Multiple randomized, controlled trials demonstrated the efficacy and superiority of mechanical thrombectomy over standard medical care in carefully selected acute ischemic stroke patients.

 

• Recent major studies demonstrated the efficacy of medical thrombectomy over standard medical care in carefully selected patients up to 24 hours after stroke onset.

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