What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review

Abstract

In 2015, mechanical thrombectomy (MT) in combination with intravenous thrombolysis was demonstrated to be superior to best medical treatment alone in patients with anterior circulation stroke. This finding resulted in an unprecedented boost in endovascular stroke therapy, and MT became widely available. MT was initially approved for patients presenting with large vessel occlusion in the anterior circulation (intracranial internal carotid artery or proximal middle cerebral artery) within a 6-hour time window. Eventually, it was shown to be beneficial in a broader group of patients, including those without known symptom-onset, wake-up stroke, or patients with posterior circulation stroke. Technical developments and the implementation of novel thrombectomy devices further facilitated endovascular recanalization for acute ischemic stroke. However, some aspects remain controversial. Is MT suitable for medium or very distal vessel occlusions? Should emergency stenting be performed for symptomatic stenosis or recurrent occlusion? How should patients with large vessel occlusion without disabling symptoms be treated? Do certain patients benefit from MT without intravenous thrombolysis? In the era of personalized decision-making, some of these questions require an individualized approach based on comorbidities, imaging criteria, and the severity or duration of symptoms. Despite its successful development in the past decade, endovascular stroke therapy will remain a challenging and fascinating field in the years to come. This review aims to provide an overview of patient selection, and the indications for and execution of MT in patients with acute ischemic stroke.

High incidence of acute and subacute ischaemic foci on brain MRI in patients with a diagnosis of acute pulmonary embolism and confirmed patent foramen ovale

“…This radiological classification of ischaemic lesions was used specifically to assess the temporal context, and is not interchangeable with the neurological classification of symptomatic ischaemic lesions (where temporal context is quite crucial in the choice of treatment, for example when thrombolytic treatment is indicated) (ref. 9 ).…”

Cardioembolic Stroke: A Matter of Prevention

“…When an acute ischemic stroke occurs, in particular when the patient is taking an anticoagulant drug, one of the main reperfusive treatment is the endovascular approach, well summarized in the review of Bucke et al [6]. The endovascular treatment of acute stroke gained a strong evidence of efficacy and the indications are progressively expanding, both because of an extension of the time window from symptoms onset and the treatment of distal vessels through a tumultuous development of technologies and materials.…”