Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-78c5997874-mlc7c Total loading time: 0 Render date: 2024-11-02T18:41:09.039Z Has data issue: false hasContentIssue false

Chapter 7 - Reperfusion of the Ischaemic Brain by Endovascular Thrombectomy and Thrombolysis

from Part III - Acute Treatment of Ischaemic Stroke and Transient Ischaemic Attack

Published online by Cambridge University Press:  15 December 2020

By
Meng Lee  and
Jeffrey L. Saver
Edited by
Jeffrey L. Saver  and
Graeme J. Hankey
Jeffrey L. Saver
Affiliation:
David Geffen School of Medicine, University of Ca
Graeme J. Hankey
Affiliation:
University of Western Australia, Perth
Get access

Summary

Endovascular thrombectomy (EVT) with highly effective reperfusion devices is beneficial for: 1) relatively broadly selected acute ischaemic stroke patients with anterior circulation large vessel occlusions (LVOs) who have failed or are ineligible for intravenous fibrinolysis, up to 7 h after onset; and 2) imaging-selected patients with a favorable penumbral profile (small core and substantial salvageable tissue) 6–24h after onset. Among early-presenting patients, benefit is strongly time-dependent; for every 4 m delay in door-to-reperfusion time, 1 of every 100 patients has a worse disability outcome. Based on the trial evidence, EVT is strongly endorsed by guidelines worldwide. Within the first 7h, benefit is evident in patients under and over age 80, and in patients with up to moderate early ischaemic changes on imaging (ASPECTS 6-10). Systems of care should be optimized to deliver likely LVO patients to endovascular-capable stroke centers, and for procedure start (arterial puncture) within 75m, and optimally within 45m, after ED arrival. Large-scale trials are testing: best prehospital recognition and routing protocols: novel device designs to increase reperfusion rates in large and also medium vessel occlusions; bridging neuroprotection and collateral enhancement; potential benefit in patients with large cores; and best concomitant therapies, including sedation mode and post-procedure blood pressure management.

Keywords

Endovascular thrombectomystent retrieveraspirationintra-arterial thrombolysisreperfusionrecanalizationhaemorrhagic transformationpenumbraischaemic stroke
Type
Chapter
Information
Stroke Prevention and Treatment
An Evidence-based Approach
 , pp. 127 - 145
Publisher: Cambridge University Press
Print publication year: 2020

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Acker, JE III, Pancioli, AM, Crocco, TJ, Eckstein, MK, Jauch, EC, Larrabee, H, et al. (2007). Implementation strategies for emergency medical services within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council. Stroke, 38(11), 3097–115.Google Scholar
Al-Mufti, F, Amuluru, K, Roth, W, Nuoman, R, El-Ghanem, M, Meyers, PM. (2018). Cerebral ischemic reperfusion injury following recanalization of large vessel occlusions. Neurosurgery, 82(6), 781–9.Google Scholar
American Heart/Stroke Association Mission Lifeline Stroke Committee. (2017). Severity-based stroke triage algorithm for EMS. www.heart.org/idc/groups/ahaecc-public/@wcm/@gwtg/documents/downloadable/ucm_492025.pdf. Accessed March 2017.Google Scholar
Badhiwala, JH, Nassiri, F, Alhazzani, W, Selim, MH, Farrokhyar, F, Spears, J, et al. (2015). Endovascular thrombectomy for acute ischemic stroke: a meta-analysis. JAMA, 314(17), 1832–43.CrossRefGoogle ScholarPubMed
Bath, PM, Lees, KR, Schellinger, PD, Altman, H, Bland, M, Hogg, C, et al. (2012). Statistical analysis of the primary outcome in acute stroke trials. Stroke, 43(4), 1171–8.Google Scholar
Bendszus, M, Thomalla, G, Hacke, W, Knauth, M, Gerloff, C, Bonekamp, S, et al.; THRILL Investigators. (2016). Early termination of THRILL, a prospective study of mechanical thrombectomy in patients with acute ischemic stroke ineligible for i.v. thrombolysis. Clin Neuroradiol, 26(4), 499–500.CrossRefGoogle ScholarPubMed
Berkhemer, OA, Fransen, PSS, Beumer, D, van den Berg, LA, Lingsma, HF, Yoo, AJ, et al. (2015). A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med, 372(1): 11–20.Google Scholar
Casaubon, L, Boulanger, J, Blacquiere, D, Bucher, S, Brown, K, Goddard, T, et al.; Heart and Stroke Foundation of Canada Canadian Stroke Best Practices Advisory Committee. (2015). Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care Guidelines, update 2015. Int J Stroke, 10(6), 924–40.CrossRefGoogle ScholarPubMed
Chapman Smith, SN, Govindarajan, P, Padrick, MM, Lippman, JM, McMurry, TL, Resler, BL, et al. (2016). A low-cost, tablet-based option for prehospital neurologic assessment: The iTREAT Study. Neurology, 87(1), 19–26.Google Scholar
Ciccone, A, Valvassori, L, Nichelatti, M, Sgoifo, A, Ponzio, M, Sterzi, R, et al. (2013). Endovascular treatment for acute ischemic stroke. N Engl J Med, 368(10), 904–13.CrossRefGoogle ScholarPubMed
Ciccone, A, Valvassori, L, Ponzio, M, Ballabio, E, Gasparotti, R, Sessa, M, et al. (2010). Intra-arterial or intravenous thrombolysis for acute ischemic stroke? The SYNTHESIS pilot trial. J Neurointerv Surg, 2(1), 74–9.Google Scholar
Ducrocq, X, Bracard, S, Taillandier, L, Anxionnat, R, Lacour, JC, Guillemin, F, et al. (2005). Comparison of intravenous and intra-arterial urokinase thrombolysis for acute ischaemic stroke. J Neuroradiol, 32(1), 26–32.Google Scholar
Fassbender, K, J. C. Grotta, JC, S. Walter, S, Grunwald, IQ, Ragoschke-Schumm, A, Saver, JL. (2017). Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges. Lancet Neurol, 16(3), 227–37.CrossRefGoogle ScholarPubMed
Feigin, VL, Norrving, B, Mensah, GA. (2017). Global burden of stroke. Circ Res, 120(3), 439–48.Google Scholar
Goyal, M, Demchuk, AM, Menon, BK, Eesa, M, Rempel, JL, Thornton, J, et al.; ESCAPE Trial Investigators. (2015). Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med, 372(11), 1019–30.CrossRefGoogle ScholarPubMed
Goyal, M, Menon, BK, Hill, MD, Demchuk, A. (2014). Consistently achieving computed tomography to endovascular recanalization <90 minutes: solutions and innovations. Stroke, 45(12), e252–6.CrossRefGoogle ScholarPubMed
Goyal, M, Menon, BK, van Zwam, WH, Dippel, DW, Mitchell, PJ, Demchuk, AM, et al.; HERMES Collaborators. (2016). Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet, 387(10029), 1723–31.Google Scholar
Goyal, N, Tsivgoulis, G, Pandhi, A, Chang, JJ, K. Dillard, K, Ishfaq, MF, et al. (2017). Blood pressure levels post mechanical thrombectomy and outcomes in large vessel occlusion strokes. Neurology, 89(6), 540–7.Google Scholar
Herzberg, M, Boy, S, Holscher, T, Ertl, M, Zimmermann, M, Ittner, KP, et al. (2014). Prehospital stroke diagnostics based on neurological examination and transcranial ultrasound. Crit Ultrasound J, 6(1), 3.Google Scholar
Higashida, R, Alberts, MJ, Alexander, DN, Crocco, TJ, Demaerschalk, BM, Derdeyn, CP, et al. (2013). Interactions within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association. Stroke, 44(10), 2961–84.Google Scholar
Hong, KS, Ko, SB, Yu, KH, Jung, C, Park, SQ, Kim, BM, et al. (2016). Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke. J Stroke, 18(1), 102–13.Google Scholar
Jadhav, AP, Kenmuir, CL, Aghaebrahim, A, Limaye, K, Wechsler, LR, Hammer, MD, et al. (2017). Interfacility transfer directly to the neuroangiography suite in acute ischemic stroke patients undergoing thrombectomy. Stroke, 48(7), 1884–9.Google Scholar
Jauch, EC, Saver, JL, Adams, HP Jr., Bruno, A, Connors, JJ, Demaerschalk, BM, et al. (2013). Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 44(3), 870–947.CrossRefGoogle ScholarPubMed
Jovin, TG, Chamorro, A, Cobo, E, de Miquel, MA, Molina, CA, Rovira, A, et al.; REVASCAT Trial Investigators. (2015). Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med, 372(24), 2296–306.Google Scholar
Kim, DH, Kim, B, Jung, C, Nam, HS, Lee, JS, Kim, JW, et al.; Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team. (2018). Consensus statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: hyperacute endovascular treatment workflow to reduce door-to-reperfusion time. J Korean Med Sci, 33(19), e143.Google Scholar
Lapergue, B, Blanc, R, Gory, B, Labreuche, J, Duhamel, A, Marnat, G, et al.; ASTER Trial Investigators. (2017). Effect of endovascular contact aspiration vs stent retriever on revascularization in patients with acute ischemic stroke and large vessel occlusion: the ASTER randomized clinical trial. JAMA, 318(5), 443–52.Google Scholar
Legrand, L, Naggara, O, G. Turc, G, Mellerio, C, Roca, P, Calvet, D, et al. (2013). Clot burden score on admission T2*-MRI predicts recanalization in acute stroke. Stroke, 44(7), 1878–84.Google Scholar
Milne, MS, Holodinsky, JK, Hill, MD, Nygren, A, Qiu, C, Goyal, M, et al. (2017). Drip ‘n’ ship versus mothership for endovascular treatment: modeling the best transportation options for optimal outcomes. Stroke, 48(3), 791–4.Google Scholar
Mocco, J, Siddiqui, A, Turk, A. (2018). A comparison of direct aspiration vs. stent retriever as a first approach (COMPASS): a randomized trial. Paper presented at the International Stroke Conference, Los Angeles, CA. https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_498785.pdf. Accessed June 2018.Google Scholar
Muir, KW, Ford, GA, Messow, CM, Ford, I, Murray, A, Clifton, A, et al.; PISTE Investigators. (2017). Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial. J Neurol Neurosurg Psychiatry, 88(1), 38–44.Google Scholar
Nogueira, RG, Frei, D, Kirmani, JF, Zaidat, O, Lopes, D, Turk, AS 3rd, et al.; Penumbra Separator 3D Investigators. (2018). Safety and efficacy of a 3-dimensional stent retriever with aspiration-based thrombectomy vs aspiration-based thrombectomy alone in acute ischemic stroke intervention: a randomized clinical trial. JAMA Neurol, 75(3), 304–11.CrossRefGoogle ScholarPubMed
Nogueira, RG, Lutsep, HL, Gupta, R, Jovin, TG, Albers, GW, Walker, GA, et al. (2012). Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet, 380(9849), 1231–40.Google Scholar
Noorian, AR, Sanossian, N, Shkirkova, K, Liebeskind, DS, Eckstein, M, Stratton, SJ, et al.; FAST-MAG Trial Investigators and Coordinators. (2018). Los Angeles Motor Scale to identify large vessel occlusion: prehospital validation and comparison with other screens. Stroke, 49(3), 565–72.Google Scholar
Nour, M, Scalzo, F, Liebeskind, DS. (2013). Ischemia-reperfusion injury in stroke. Interv Neurol, 1(3–4), 185–99.Google Scholar
O’Rourke, K, Berge, E, Walsh, CD, Kelly, PJ. (2010). Percutaneous vascular interventions for acute ischaemic stroke. Cochrane Database Syst Rev, 10, CD007574.Google Scholar
Persson, M, Fhager, A, Trefna, HD, Yu, Y, McKelvey, T, Pegenius, G, et al. (2014). Microwave-based stroke diagnosis making global prehospital thrombolytic treatment possible. IEEE Trans Biomed Eng, 61(11), 2806–17.Google Scholar
Pontes-Neto, OM, Cougo, P, Martins, SC, Abud, DG, Nogueira, RG, Miranda, M, et al. (2017). Brazilian guidelines for endovascular treatment of patients with acute ischemic stroke. Arq Neuropsiquiatr, 75(1), 50–6.CrossRefGoogle ScholarPubMed
Powers, WJ, Rabinstein, AA, Ackerson, T, Adeoye, OM, Bambakidis, NC, Becker, K, et al.; American Heart Association Stroke Council. (2018). 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49(3), e46–110.Google Scholar
Rajajee, V, Kidwell, C, Starkman, S, Ovbiagele, B, Alger, JR, Villablanca, P, et al. (2006). Early MRI and outcomes of untreated patients with mild or improving ischemic stroke. Neurology, 67(6), 980–4.Google Scholar
Ribo, M.; RACECAT Trialists. (2017). Direct transfer to an endovascular center compared to transfer to the closest stroke center in acute stroke patients with suspected large vessel occlusion (RACECAT). NCT02795962. https://clinicaltrials.gov/ct2/show/NCT02795962. Accessed June 2018.Google Scholar
Rodrigues, FB, Neves, JB, Caldeira, D, Ferro, JM, Ferreira, JJ, Costa, J. (2016). Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis. BMJ, 353, i1754.Google Scholar
Saver, JL. (2011). Optimal end points for acute stroke therapy trials: best ways to measure treatment effects of drugs and devices. Stroke, 42(8), 2356–62.Google Scholar
Saver, JL. (2013). The 2012 Feinberg lecture: treatment swift and treatment sure. Stroke, 44(1), 270–7.Google Scholar
Saver, JL, Goyal, M, van der Lugt, A, Menon, BK, Majoie, CB, Dippel, DW, et al.; HERMES Collaborators. (2016). Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA, 316(12), 1279–88.Google Scholar
Saver, JL, Jahan, R, Levy, EI, Jovin, TG, Baxter, B, Nogueira, RG, et al. (2012). Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet, 380(9849), 1241–9.Google Scholar
Smith, EE, Kent, DM, Bulsara, KR, Leung, LY, Lichtman, JH, Reeves, MJ, et al.; American Heart Association Stroke Council. (2018). Accuracy of prediction instruments for diagnosing large vessel occlusion in individuals with suspected stroke: a systematic review for the 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke. Stroke, 49(3), e111–22.Google Scholar
Tokunboh, I, Vales Montero, M, Zopelaro Almeida, MF, Sharma, L, Starkman, S, Szeder, V, et al. (2018). Visual aids for patient, family, and physician decision making about endovascular thrombectomy for acute ischemic stroke. Stroke, 49(1), 90–7.Google Scholar
Ventz, S, Barry, WT, Parmigiani, G, Trippa, L. (2017). Bayesian response-adaptive designs for basket trials. Biometrics, 73(3), 905–15.Google Scholar
Wahlgren, N, Moreira, T, Michel, P, Steiner, T, Jansen, O, Cognard, C, et al. (2016). Mechanical thrombectomy in acute ischemic stroke: consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN. Int J Stroke, 11(1), 134–47.Google Scholar
Wang, H, Thevathasan, A, Dowling, R, Bush, S, Mitchell, P, Yan, B. (2017). Streamlining workflow for endovascular mechanical thrombectomy: lessons learned from a comprehensive stroke center. J Stroke Cerebrovasc Dis, 26(8), 1655–62.Google Scholar
Wardlaw, JM, Murray, V, Berge, E, del Zoppo, GJ. (2014). Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev, 7, CD000213.Google Scholar
Wheeler, HM, Mlynash, M, Inoue, M, Tipimini, A, Liggins, J, Bammer, R, et al.; DEFUSE 2 Investigators. (2015). The growth rate of early DWI lesions is highly variable and associated with penumbral salvage and clinical outcomes following endovascular reperfusion. Int J Stroke, 10(5), 723–9.Google Scholar
Zaidat, OO, Bozorgchami, H, Ribo, M, Saver, JL, Mattle, HP, Chapot, R, et al. (2018a). Primary results of the multicenter ARISE II study (Analysis of Revascularization in Ischemic Stroke with EmboTrap). Stroke, 49(5), 1107–15.Google Scholar
Zaidat, OO, Castonguay, AC, Linfante, I, Gupta, R, Martin, CO, Holloway, WE, et al. (2018b). First pass effect: a new measure for stroke thrombectomy devices. Stroke, 49(3): 660–6.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×