J Korean Neurosurg Soc.  2024 Jul;67(4):397-410. 10.3340/jkns.2023.0181.

Endovascular Thrombectomy for Acute Ischemic Stroke : Current Concept in Management

• Bae JW
• Hyun DK

• KMID: 2556737
• DOI: http://doi.org/10.3340/jkns.2023.0181

Abstract

Endovascular thrombectomy (EVT) has been established as the standard of care in the treatment of acute ischemic stroke (AIS) based on landmark randomized controlled trials. Nevertheless, while the strict eligibility of EVT for AIS patients restrict the wide application of EVT, a considerable population still undergoes off-label EVT. Besides, it is important to acknowledge that recanalization is not achieved in approximately 20% of procedures, and more than 50% of patients who undergo EVT still do not experience a favorable outcome. This article reviews the brief history of EVT trials and recent progressions in the treatment of AIS, with focusing on the expanding eligibility criteria, new target for EVT, and the evolution of EVT techniques.

Keyword

Ischemic stroke; Thrombectomy; Mechanial thrombolysis

Figure

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  Fig. 1. Chronology in the history of randomized controlled trials investigating eligibility of endovascular thrombectomy in acute ischemic stroke patients. NINDS : National Institute of Neurological Disorders and Stroke, IV tPA : intravenous tissue plasminogen activator, PROACT : Prolyse in Acute Cerebral Thromboembolism, IA : intra-arterial, ECASS : European Cooperative Acute Stroke Study trial, SYNTHESIS : Local versus Systemic Thrombolysis for Acute Ischemic Stroke, IMS : Interventional Management of Stroke, MR RESCUE : Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy, EXTEND IA : Extending the Time for Thrombolysis in Emergency Neurological Deficits - Intra-Arterial, MR CLEAN : Multicenter Randomized Clinical trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands, SWIFT PRIME : Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment, REVASCAT : Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset, ESCAPE : Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke, HERMES : Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke, DAWN : DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo, DEFUSE : Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke, RESCUE-Japan LIMIT : Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Large Ischemic Core Trial, ANGEL-ASPECT : Endovascular therapy in acute anterior circulation large vessel occlusive patients with a large infarct core, SELECT 2 : Randomized Controlled Trial to Optimize Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke, TENSION : Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window, TESLA : Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke, LASTE : Large Stroke Therapy Evaluation, BEST : Basilar Artery Occlusion Endovascular Intervention Versus Standard Medical Treatment, BASICS : Basilar Artery International Cooperation Study, ATTENTION : Endovascular Treatment for Acute Basilar Artery Occlusion trial, BAOCHE : Basilar Artery Occlusion Chinese Endovascular, ENDOLOW : Endovascular therapy for low NIHSS ischemic stroke, MOSTE : Minor Stroke Therapy Evaluation.

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  Fig. 2. The number needed to treat for randomized controlled trials of endovascular thrombectomy in acute ischemic stroke patients. NINDS : National Institute of Neurological Disorders and Stroke, ECASS : European Cooperative Acute Stroke Study trial, MR CLEAN : Multicenter Randomized Clinical trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands, THRACE : Mechanical Thrombectomy After Intravenous Alteplase Versus Alteplase Alone After Stroke, REVASCAT : Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset, ESCAPE : Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke, EXTEND IA : Extending the Time for Thrombolysis in Emergency Neurological De cits - Intra-Arterial, SWIFT PRIME : Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment, HERMES : Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke, DAWN : DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo, DEFUSE : Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke, RESCUE-Japan : Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan, ANGEL-ASPECT : Endovascular therapy in acute anterior circulation large vessel occlusive patients with a large infarct core, SELECT 2 : Randomized Controlled Trial to Optimize Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke, BEST : Basilar Artery Occlusion Endovascular Intervention Versus Standard Medical Treatment, BASICS : Basilar Artery International Cooperation Study, ATTENTION : Endovascular Treatment for Acute Basilar Artery Occlusion trial, BAOCHE : Basilar Artery Occlusion Chinese Endovascular, IV tPA : intravenous tissue plasminogen activator, EVT : endovascular thrombectomy.

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  Fig. 3. Inclusion criteria of randomized controlled trials of large core infarction. MR : magnetic resonance, ASPECTS : Alberta Stroke Program Early Computed Tomography Score, CT : computed tomography, SELECT 2 : Randomized Controlled Trial to Optimize Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke, ANGEL-ASPECT : Endovascular therapy in acute anterior circulation large vessel occlusive patients with a large infarct core, LASTE : Large Stroke Therapy Evaluation, TESLA : Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke, RESCUE-Japan LIMIT : Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Large Ischemic Core trial, TENSION : Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window, EVT : endovascular thrombectomy.

Reference

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