J Korean Neurosurg Soc.  2020 Jul;63(4):427-432. 10.3340/jkns.2019.0151.

Paradigm Shift in Intra-Arterial Mechanical Thrombectomy for Acute Ischemic Stroke : A Review of Randomized Controlled Trials after 2015

• Sheen JJ
• Kim YW

• KMID: 2504636
• DOI: http://doi.org/10.3340/jkns.2019.0151

Abstract

Three randomized control trials (RCTs), published in 2013, investigated efficacy of mechanical thrombectomy in large vessel occlusions and did not show better results compared to intravenous (IV) recombinant tissue-type plasminogen activator (tPA) alone. However, most clinicians treating stroke consider mechanical thrombectomy as the standard treatment rather than using IV tPA alone. This paradigm shift was based on five RCTs investigating efficacy of mechanical thrombectomy in acute ischemic stroke conducted from 2010 to 2015. They demonstrated that mechanical thrombectomy was effective and safe in acute ischemic stroke with anterior circulation occlusion when performed within 6 hours of stroke onset. There are four reasons underlying the different results observed between the trials conducted in 2013 and 2015. First, the three RCTs of 2013 used low-efficiency thrombectomy devices. Second, the three RCTs used insufficient image selection criteria. Third, following the initial presentation at the hospital, reperfusion treatment required a long time. Fourth, the three RCTs showed a low rate of successful recanalization. Time is the most important factor in the treatment of acute ischemic stroke. However, current trends utilize advanced imaging techniques, such as diffusion-weighted imaging and multi-channel computer tomographic perfusion, to facilitate the detection of core infarction, penumbra, and collateral flows. These efforts demonstrate that patient selection may overcome the barriers of time in specific cases.

Keyword

Stroke; Infarction; Thrombectomy

Figure

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  Fig. 1. 2018 Stroke guidelines extend the thrombectomy window to 24 hours. In selected patients with acute ischemic stroke who have large vessel occlusion in the anterior circulation, mechanical thrombectomy is recommended 1) within 6 to 16 hours of last known normal and meet DAWN or DEFUSE 3 eligibility criteria and 2) within 16 to 24 hours of last known normal and meet DAWN eligibility criteria. 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.

Reference

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