Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Current Neurology and Neuroscience Reports
Published in: Current Neurology and Neuroscience Reports 9/2017

01-09-2017 | Stroke (H Diener, Section Editor)

Unresolved Issues in Thrombectomy

Authors: Mahesh V. Jayaraman, Ryan A. McTaggart, Mayank Goyal

Published in: Current Neurology and Neuroscience Reports | Issue 9/2017

Login to get access

Abstract

Purpose of Review

Trials demonstrating marked benefit of mechanical thrombectomy (MT) for acute stroke caused by large vessel occlusion (LVO) in the anterior circulation have been the most significant advance in acute ischemic stroke in the past 20 years. However, despite this marked advance, there are still many hurdles to improving access to thrombectomy worldwide. Additionally, despite these advances, a substantial portion of patients with LVO still are left disabled.

Recent Findings

The major randomized trials focused on patients within 6 h from symptom onset, with occlusion of the ICA or proximal MCA, small amount of permanently damaged brain, and a moderate to large clinical deficit. We will explore the role of thrombectomy outside of these areas, but also explore larger issues as they pertain to re-organization of stroke systems of care to improve access to this remarkable therapy.

Summary

Now that we have proven, without a shadow of doubt, that rapid revascularization with mechanical thrombectomy improves outcomes in LVO stroke, we must reorganize our systems of care to improve access and assess the role for MT outside of the patients who meet trial criteria.
Literature
1.
Lima FO, Furie KL, Silva GS, Lev MH, Camargo EC, Singhal AB, et al. Prognosis of untreated strokes due to anterior circulation proximal intracranial arterial occlusions detected by use of computed tomography angiography. JAMA neurology. 2014;71:151–7.CrossRefPubMed
2.
• Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-pa vs. T-pa alone in stroke. N Engl J Med. 2015;372:2285–95. One of the five major randomized trials published in 2015 first demonstrating a benefit to thrombectomy in addition to best medical therapy. CrossRefPubMed
3.
• Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–306. One of the five major randomized trials published in 2015 first demonstrating a benefit to thrombectomy in addition to best medical therapy. CrossRefPubMed
4.
• Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30. One of the five major randomized trials published in 2015 first demonstrating a benefit to thrombectomy in addition to best medical therapy.
5.
• Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–18. One of the five major randomized trials published in 2015 first demonstrating a benefit to thrombectomy in addition to best medical therapy. CrossRefPubMed
6.
• Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20. One of the five major randomized trials published in 2015 first demonstrating a benefit to thrombectomy in addition to best medical therapy. CrossRefPubMed
7.
•• Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016. This is a patient level, pooled meta-analysis of the five major thrombectomy trials published in 2015. It showed remarkable homogeneity of treatment effect across all subgroups, including age, and severity of clinical deficit.
8.
•• Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316:1279–88. This detailed analysis of the time decay curve of the benefit of thrombectomy shows that for every four minute delay to substantial reperfusion, one more patient has a worse outcome. CrossRefPubMed
9.
Rai AT, Seldon AE, Boo S, Link PS, Domico JR, Tarabishy AR, et al. A population-based incidence of acute large vessel occlusions and thrombectomy eligible patients indicates significant potential for growth of endovascular stroke therapy in the USA. J Neurointerv Surg 2016.
10.
Chia NH, Leyden JM, Newbury J, Jannes J, Kleinig TJ. Determining the number of ischemic strokes potentially eligible for endovascular thrombectomy: a population-based study. Stroke. 2016;47:1377–80.CrossRefPubMed
11.
Perez de la Ossa N, Carrera D, Gorchs M, Querol M, Millan M, Gomis M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke. 2014;45:87–91.CrossRefPubMed
12.
Nazliel B, Starkman S, Liebeskind DS, Ovbiagele B, Kim D, Sanossian N, et al. A brief prehospital stroke severity scale identifies ischemic stroke patients harboring persisting large arterial occlusions. Stroke. 2008;39:2264–7.CrossRefPubMedPubMedCentral
13.
Teleb MS, Ver Hage A, Carter J, Jayaraman MV, McTaggart RA. Stroke vision, aphasia, neglect (van) assessment-a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices. J Neurointerv Surg. 2017;9:122–6.CrossRefPubMed
14.
Lima FO, Silva GS, Furie KL, Frankel MR, Lev MH, Camargo EC, et al. Field assessment stroke triage for emergency destination: a simple and accurate prehospital scale to detect large vessel occlusion strokes. Stroke. 2016;47:1997–2002.CrossRefPubMedPubMedCentral
15.
Turc G, Maier B, Naggara O, Seners P, Isabel C, Tisserand M, et al. Clinical scales do not reliably identify acute ischemic stroke patients with large-artery occlusion. Stroke. 2016;47:1466–72.CrossRefPubMed
16.
•• Zhao H, Coote S, Pesavento L, Churilov L, Dewey HM, Davis SM, et al. Large vessel occlusion scales increase delivery to endovascular centers without excessive harm from misclassifications. Stroke. 2017;48:568–73. This mathematical model shows how dramatic the effect of field triage to endovascular centers is. If 90% recanalization can be achieved, patients within a 90-min radius of an endovascular center should be directly transported for best possible outcomes. CrossRefPubMed
17.
Milne MS, Holodinsky JK, Hill MD, Nygren A, Qiu C, Goyal M, et al. Drip 'n ship versus mothership for endovascular treatment: modeling the best transportation options for optimal outcomes. Stroke. 2017;
18.
Holodinsky JK, Williamson TS, Kamal N, Mayank D, Hill MD, Goyal M. Drip and ship versus direct to comprehensive stroke center: conditional probability modeling. Stroke. 2017;48:233–8.CrossRefPubMed
19.
Jayaraman MV, Iqbal A, Silver B, Siket MS, Amedee C, McTaggart RA, et al. Developing a statewide protocol to ensure patients with suspected emergent large vessel occlusion are directly triaged in the field to a comprehensive stroke center: how we did it. J Neurointerv Surg 2016.
20.
Mokin M, Gupta R, Guerrero WR, Rose DZ, Burgin WS, Sivakanthan S. Aspects decay during inter-facility transfer in patients with large vessel occlusion strokes. J Neurointerv Surg 2016.
21.
Fuentes B, Alonso de Lecinana M, Ximenez-Carrillo A, Martinez-Sanchez P, Cruz-Culebras A, Zapata-Wainberg G, et al. Futile interhospital transfer for endovascular treatment in acute ischemic stroke: the Madrid stroke network experience. Stroke. 2015;46:2156–61.CrossRefPubMed
22.
Yi J, Zielinski D, Ouyang B, Conners J, Dafer R, Chen M. Predictors of false-positive stroke thrombectomy transfers. J Neurointerv Surg 2017.
23.
•• McTaggart RA, Yaghi S, Cutting SM, Hemendinger M, Baird GL, Haas RA, et al. Association of a primary stroke center protocol for suspected stroke by large-vessel occlusion with efficiency of care and patient outcomes. JAMA Neurol 2017. This paper demonstrates how an optimized transfer protocol using early CTA from non-endovascular capable centers directly to an endovascular center can dramatically improve times and outcomes.
24.
Wendt M, Ebinger M, Kunz A, Rozanski M, Waldschmidt C, Weber JE, et al. Improved prehospital triage of patients with stroke in a specialized stroke ambulance: results of the pre-hospital acute neurological therapy and optimization of medical care in stroke study. Stroke. 2015;46:740–5.CrossRefPubMed
25.
Ebinger M, Kunz A, Wendt M, Rozanski M, Winter B, Waldschmidt C, et al. Effects of golden hour thrombolysis: a prehospital acute neurological treatment and optimization of medical care in stroke (phantom-s) substudy. JAMA Neurol. 2015;72:25–30.CrossRefPubMed
26.
Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen T, et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol. 2012;11:397–404.CrossRefPubMed
27.
Cook DJ, Teves L, Tymianski M. Treatment of stroke with a psd-95 inhibitor in the gyrencephalic primate brain. Nature. 2012;483:213–7.CrossRefPubMed
28.
Hill MD, Martin RH, Mikulis D, Wong JH, Silver FL, TerBrugge KG, et al. Safety and efficacy of na-1 in patients with iatrogenic stroke after endovascular aneurysm repair (enact): a phase 2, randomised, double-blind, placebo-controlled trial. Lancet Neurol. 2012;11:942–50.CrossRefPubMed
29.
Goyal M, Fargen KM, Menon BK. Acute stroke, Bayes’ theorem and the art and science of emergency decision-making. J Neurointerv Surg. 2014;6:256–9.CrossRefPubMed
30.
Hill MD, Goyal M, Demchuk AM, Fisher M. Ischemic stroke tissue-window in the new era of endovascular treatment. Stroke. 2015;46:2332–4.CrossRefPubMed
31.
Hakimelahi R, Vachha BA, Copen WA, Papini GD, He J, Higazi MM, et al. Time and diffusion lesion size in major anterior circulation ischemic strokes. Stroke. 2014;45:2936–41.CrossRefPubMed
32.
Nogueira RGJT. Dawn trial results. ESO 2017. 2017.
33.
• Heldner MR, Hsieh K, Broeg-Morvay A, Mordasini P, Buhlmann M, Jung S, et al. Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible? J Neurol. 2016;263:1633–40. This paper illustrates how no clinical scale can safely exclude ELVO and vessel imaging is needed on all stroke patients. CrossRefPubMed
34.
Rajajee V, Kidwell C, Starkman S, Ovbiagele B, Alger JR, Villablanca P, et al. Early MRI and outcomes of untreated patients with mild or improving ischemic stroke. Neurology. 2006;67:980–4.CrossRefPubMed
35.
Heldner MR, Jung S, Zubler C, Mordasini P, Weck A, Mono ML, et al. Outcome of patients with occlusions of the internal carotid artery or the main stem of the middle cerebral artery with nihss score of less than 5: comparison between thrombolysed and non-thrombolysed patients. J Neurol Neurosurg Psychiatry 2014.
36.
Haussen DC, Bouslama M, Grossberg JA, Anderson A, Belagage S, Frankel M, et al. Too good to intervene? Thrombectomy for large vessel occlusion strokes with minimal symptoms: an intention-to-treat analysis. J Neurointerv Surg 2016.
37.
McTaggart RA, Jovin TG, Lansberg MG, Mlynash M, Jayaraman MV, Choudhri OA, et al. Alberta stroke program early computed tomographic scoring performance in a series of patients undergoing computed tomography and MRI: reader agreement, modality agreement, and outcome prediction. Stroke. 2015;46:407–12.CrossRefPubMed
38.
Borst J, Berkhemer OA, Roos YB, van Bavel E, van Zwam WH, van Oostenbrugge RJ, et al. Value of computed tomographic perfusion-based patient selection for intra-arterial acute ischemic stroke treatment. Stroke. 2015;46:3375–82.CrossRefPubMed
39.
Desilles JP, Consoli A, Redjem H, Coskun O, Ciccio G, Smajda S, et al. Successful reperfusion with mechanical thrombectomy is associated with reduced disability and mortality in patients with pretreatment diffusion-weighted imaging-Alberta stroke program early computed tomography score ≤6. Stroke. 2017;48:963–9.CrossRefPubMed
40.
Gilgen MD, Klimek D, Liesirova KT, Meisterernst J, Klinger-Gratz PP, Schroth G, et al. Younger stroke patients with large pretreatment diffusion-weighted imaging lesions may benefit from endovascular treatment. Stroke. 2015;46:2510–6.CrossRefPubMed
41.
Khan M, Goddeau RP Jr, Zhang J, Moonis M, Henninger N. Predictors of outcome following stroke due to isolated M2 occlusions. Cerebrovasc Dis Extra. 2014;4:52–60.CrossRefPubMedPubMedCentral
42.
Flores A, Tomasello A, Cardona P, de Miquel MA, Gomis M, Garcia Bermejo P, et al. Endovascular treatment for M2 occlusions in the era of stentrievers: a descriptive multicenter experience. J Neurointerv Surg. 2015;7:234–7.CrossRefPubMed
43.
Coutinho JM, Liebeskind DS, Slater LA, Nogueira RG, Baxter BW, Levy EI, et al. Mechanical thrombectomy for isolated M2 occlusions: a post hoc analysis of the star, swift, and swift prime studies. AJNR Am J Neuroradiol. 2016;37:667–72.CrossRefPubMed
44.
Deipolyi AR, Hamberg LM, Gonzalez RG, Hirsch JA, Hunter GJ. Diagnostic yield of emergency department arch-to-vertex CT angiography in patients with suspected acute stroke. AJNR Am J Neuroradiol. 2015;36:265–8.CrossRefPubMed
45.
Saqqur M, Uchino K, Demchuk AM, Molina CA, Garami Z, Calleja S, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke. 2007;38:948–54.CrossRefPubMed
46.
Akpinar CK, Gurkas E, Aytac E. Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting may be a better option in acute tandem occlusions. Interv Neuroradiol 2017:1591019917701113.
47.
Al-Mufti F, Amuluru K, Manning NW, Khan I, Peeling L, Gandhi CD, et al. Emergent carotid stenting and intra-arterial abciximab in acute ischemic stroke due to tandem occlusion. Br J Neurosurg 2017:1–7.
48.
Mpotsaris A, Kabbasch C, Borggrefe J, Gontu V, Soderman M. Stenting of the cervical internal carotid artery in acute stroke management: the Karolinska experience. Interv Neuroradiol. 2017;23:159–65.CrossRefPubMed
49.
Rangel-Castilla L, Rajah GB, Shakir HJ, Shallwani H, Gandhi S, Davies JM, et al. Management of acute ischemic stroke due to tandem occlusion: should endovascular recanalization of the extracranial or intracranial occlusive lesion be done first? Neurosurg Focus. 2017;42:E16.CrossRefPubMed
50.
Prabhakaran S, Castonguay AC, Gupta R, Sun CJ, Martin CO, Holloway W, et al. Complete reperfusion mitigates influence of treatment time on outcomes after acute stroke. J Neurointerv Surg. 2017;9:366–9.CrossRefPubMed
51.
McTaggart RA, Tung EL, Yaghi S, Cutting SM, Hemendinger M, Gale HI, et al. Continuous aspiration prior to intracranial vascular embolectomy (captive): a technique which improves outcomes. J Neurointerv Surg. 2016;
52.
Maus V, Behme D, Kabbasch C, Borggrefe J, Tsogkas I, Nikoubashman O, et al. Maximizing first-pass complete reperfusion with save. Clin Neuroradiol. 2017;
53.
Humphries W, Hoit D, Doss VT, Elijovich L, Frei D, Loy D, et al. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J Neurointerv Surg. 2015;7:90–4.CrossRefPubMed
54.
Massari F, Henninger N, Lozano JD, Patel A, Kuhn AL, Howk M, et al. Arts (aspiration-retriever technique for stroke): initial clinical experience. Interv Neuroradiol. 2016;22:325–32.CrossRefPubMedPubMedCentral
55.
Chueh JY, Puri AS, Gounis MJ. An in vitro evaluation of distal emboli following Lazarus Cover-assisted stent retriever thrombectomy. J Neurointerv Surg. 2017;9:183–7.CrossRefPubMed
56.
Mokin M, Setlur Nagesh SV, Ionita CN, Mocco J, Siddiqui AH. Stent retriever thrombectomy with the cover accessory device versus proximal protection with a balloon guide catheter: in vitro stroke model comparison. J Neurointerv Surg. 2016;8:413–7.CrossRefPubMed
57.
Lavine SD, Cockroft K, Hoh B, Bambakidis N, Khalessi AA, Woo H, et al. Training guidelines for endovascular ischemic stroke intervention: an international multi-society consensus document. AJNR Am J Neuroradiol. 2016;37:E31–4.CrossRefPubMed
58.
Widimsky P, Koznar B, Peisker T, Vasko P, Vavrova J, Stetkarova I. Direct catheter-based thrombectomy in acute ischaemic stroke performed collaboratively by cardiologists, neurologists and radiologists: the single-centre pilot experience (prague-16 study). EuroIntervention. 2014;10:869–75.CrossRefPubMed
59.
Burkart DJ, Day JS, Henderson K, Borsa JJ. Efficacy of peripheral interventional radiologists performing endovascular stroke therapy guided by CT perfusion triage of patients. J Vasc Interv Radiol. 2013;24:1267–72.CrossRefPubMed
60.
Fjetland L, Roy S, Kurz KD, Larsen JP, Kurz MW. Endovascular acute stroke treatment performed by vascular interventional radiologists: is it safe and efficacious? Cardiovasc Intervent Radiol. 2012;35:1029–35.CrossRefPubMed
61.
Rinaldo L, Brinjikji W, Rabinstein AA. Transfer to high-volume centers associated with reduced mortality after endovascular treatment of acute stroke. Stroke. 2017;48:1316–21.CrossRefPubMed
62.
Nguyen N, Eagleson R, Boulton M, de Ribaupierre S. Realism, criterion validity, and training capability of simulated diagnostic cerebral angiography. Stud Health Technol Inform. 2014;196:297–303.PubMed
63.
Spiotta AM, Rasmussen PA, Masaryk TJ, Benzel EC, Schlenk R. Simulated diagnostic cerebral angiography in neurosurgical training: a pilot program. J Neurointerv Surg. 2013;5:376–81.CrossRefPubMed
64.
Chaisinanunkul N, Adeoye O, Lewis RJ, Grotta JC, Broderick J, Jovin TG, et al. Adopting a patient-centered approach to primary outcome analysis of acute stroke trials using a utility-weighted modified Rankin scale. Stroke. 2015;46:2238–43.CrossRefPubMedPubMedCentral
65.
Meretoja A, Keshtkaran M, Tatlisumak T, Donnan GA, Churilov L. Endovascular therapy for ischemic stroke: save a minute-save a week. Neurology 2017.
Metadata
Title
Unresolved Issues in Thrombectomy
Authors
Mahesh V. Jayaraman
Ryan A. McTaggart
Mayank Goyal
Publication date
01-09-2017
Publisher
Springer US
Published in
Current Neurology and Neuroscience Reports / Issue 9/2017
Print ISSN: 1528-4042
Electronic ISSN: 1534-6293
DOI
https://doi.org/10.1007/s11910-017-0776-4

Other articles of this Issue 9/2017

Current Neurology and Neuroscience Reports 9/2017 Go to the issue

Epilepsy (CW Bazil, Section Editor)

Brain Tumor-Related Epilepsy: a Current Review of the Etiologic Basis and Diagnostic and Treatment Approaches

Epilepsy (CW Bazil, Section Editor)

Laser Interstitial Thermal Therapy for Epilepsy

Dementia (K Marder, Section Editor)

Emerging Diagnostic and Therapeutic Strategies for Tauopathies

Epilepsy (CW Bazil, Section Editor)

Psychogenic Non-Epileptic Seizures

Dementia (K Marder, Section Editor)

New Therapeutic Strategies for Lewy Body Dementias

Stroke (H Diener, Section Editor)

Non-Vitamin K Oral Anticoagulants (NOACs) and Their Reversal