Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next?

Abstract

In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.

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“…Randomized and controlled trials have demonstrated that AIS patients treated with EVT had a higher rate of successful recanalization, more favorable clinical outcomes, and longer therapeutic window compared with thrombolytic therapy [ 2 , 3 ]. However, futile recanalization, which is defined as patients having unfavorable outcomes (mRS of 3–6) despite successful recanalization (mTICI of 2b–3), remains a major clinical challenge to predict and is poorly understood [ 4 , 5 ].…”

“…However, futile recanalization, which is defined as patients having unfavorable outcomes (mRS of 3–6) despite successful recanalization (mTICI of 2b–3), remains a major clinical challenge to predict and is poorly understood [ 4 , 5 ]. There is no reliable clinical, blood, or radiological markers to predict outcomes after EVT [ 3 , 32 ], except for more generic measurements such as age, stroke severity, general anesthesia, and hyperglycemia (glycated hemoglobin > 6.5%) for predicting poor prognosis of patients after EVT [ 5 , 32 ]. Biomarkers detected in the peripheral blood of patients could have better predictive values because they are often related to pathophysiological response to EVT recanalization.…”

“…For patients with acute ischemic stroke (AIS), the primary therapeutic aim is timely and effective recanalization of the occluded blood vessels by thrombolytic therapy or endovascular thrombectomy (EVT) [ 1 , 2 ]. EVT, alone or in combination with intravenous thrombolysis (bridging strategy), achieves > 80% of recanalization and markedly improves clinical outcomes of AIS patients caused by large vessel occlusion (LVO) to proximal anterior circulation [ 3 ]. However, many AIS patients who achieved successful recanalization develop early complications (e.g., secondary infarct growth, symptomatic hemorrhagic transformation, and malignant edema), and ~ 50% of these patients remain disabled several months post-EVT.…”

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“…The effective treatment time window of rt-PA is 4.5 h, and patients with large artery occlusion can be treated with thrombectomy within 6 h or even beyond 24 h of symptom onset. However, nearly 60% of patients did not achieve functional independence at 3 months after treatment in recent mechanical thrombectomy trials ( Rabinstein, 2020 ; Shafie and Yu, 2021 ). When ischemic stroke occurs, apoptosis or necrosis of various cells is seen in the infarct areas.…”

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“…The major success stories for treating brain injury have been the use of thrombolytic therapy and endovascular thrombectomy for ischemic stroke [1][2][3]. As a therapy, thrombectomy has been approved for a much shorter time than thrombolysis and, as reviewed by Shafie and Yu [4], we are still exploring the limits of thrombectomy as a therapy. As described by Kang et al [5], one big question is the therapeutic time window and the extent to which imaging can identify patient sub-populations that will benefit from delayed thrombectomy.…”