Emergency thrombectomy for acute ischaemic stroke: current evidence, international guidelines, and local clinical practice

Abstract

Acute ischaemic stroke due to large vessel occlusion leads to grave neurological morbidity and mortality. Conventional intravenous thrombolysis is ineffective in achieving timely reperfusion in this group of patients. The publication of five positive randomised controlled trials of emergency thrombectomy for acute ischaemic stroke in 2015 provided strong evidence to support endovascular reperfusion therapy and represented a paradigm shift in acute stroke management. In this article, we review the current evidence and international guidelines, and report on the findings of a survey study of the clinical practice and opinions of local neurologists, neurosurgeons, and interventional radiologists in emergency thrombectomy. We also discuss the controversies around thrombectomy treatment, local experience, and suggestions to incorporate

We need a stroke system

“…2 The introduction of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) has provided us with reliable tools to address these challenges-both IVT and MT are proven and clinically accessible treatments that can significantly improve patient outcomes. 3 But while IVT is, arguably, fairly well established in Hong Kong, the provision of MT, as demonstrated by Tsang et al 4 in this issue, remains uncoordinated, patchy, and inconsistent.…”

Burden of large vessel occlusion stroke and the service gap of thrombectomy: A population-based study using a territory-wide public hospital system registry

“…Although the clinical efficacy and cost-effectiveness of endovascular thrombectomy had been proven, universal access to this treatment remains a challenge in Asia including better-off economies like Hong Kong. [19][20][21][22] This is exemplified by the fact that less than 10% of potentially thrombectomy-eligible LVO patients were treated in 2016. With indications for thrombectomy rapidly expanding to patients with delayed presentation up to 24 h and distal artery occlusions, this service gap is likely to widen.…”

New Advances in Acute Ischemic Stroke Management: Review Article

“…Such a therapeutic strategy resulted from a trial conducted by the National Institute of Neurological Disorders and Stroke in 1995, where the patients who underwent tIV-tPA therapy over 3 hours of initial symptoms had a higher possibility of 30% for not having a disability or minimal disability compared to placebo. 24 According to the European Cooperative Acute Stroke Study III, such a therapeutic window then got longer up to 4.5 hours from symptom onset, revealing the same profits of administration of IV-tPA for the duration of 3-4.5 hours. 25 However, in case of significant cerebral artery occlusion as the involvement of the intracranial internal carotid artery or the first and second segment of the middle cerebral artery (M1, M2), the efficacy of IV-tPA was inefficient showing a recanalization rate of just 4%-30%.…”

“…[30][31][32][33][34] After that, emergent thrombectomy has globally considered as the leading standard for handling the patients with AIS originating by a significant vessel occlusion and is now advised in all instructions to be used for a major stroke. 24 Advances in AIS Treatment Emphasizing on the Emergent Thrombectomy In comparison to the former negative thrombectomy, one of the considerable advances was the introduction of newer stent retriever devices leading to a higher rate of recanalization. In this new trend, a nearly complete recanalization (TICI 2b/3) was realized among 59%-88% of patients, by analogy to intra-arterial tPA and firstgeneration devices with an achievement among 25%-41% of patients.…”

“…In this new trend, a nearly complete recanalization (TICI 2b/3) was realized among 59%-88% of patients, by analogy to intra-arterial tPA and firstgeneration devices with an achievement among 25%-41% of patients. 24 The other thrombectomy device used in 2016 was the direct aspiration catheter (ADAPT technique) employing for removal of the thrombosis through a large-bore endovascular catheter. The multiple single-center series supported the ADAPT, demonstrating remarkable result, and even higher than previous stent retrievers.…”