25 - Cerebrovascular interventions

Abstract

Acute ischemic stroke therapy has evolved greatly over the past decade. Mechanical thrombectomy with stent retrievers or suction catheters has emerged as a highly effective treatment for stroke caused by large vessel occlusions. It greatly reduces disability, can reduce mortality rates, and is safe when combined with intravenous thrombolysis. Thrombectomy can be performed up to 24 hours after stroke onset as long as there is salvageable brain tissue at risk but should be avoided in those with large areas of acute infarction (i.e., patient selection is critical for success and avoiding symptomatic intracranial hemorrhage). There remain many unanswered questions, especially regarding treatment of patients with vertebrobasilar occlusions who were excluded from the randomized trials. Elective interventions for intracranial stenosis, on the other hand, have not been proven safe and effective; to the contrary, the largest randomized trial showed increased morbidity and mortality with a self-expanding stent compared with medical therapy alone. These data do not tell the whole story, and in selected patients who have recurrent ischemia despite dual antiplatelet therapy, high-dose statins (i.e., maximal medical therapy), treatment with angioplasty and stenting should be considered. This is particularly true of patients who have exhausted cerebrovascular reserve for whom stroke risk may be as high as 20% to 25% annually. The only US Food and Drug Administration–approved device designed for intracranial delivery is a self-expanding device with poor radial force. Consequently, coronary balloon-expandable stents, especially drug-eluting devices, have been used to good effect. This approach is experimental, and randomized data are lacking.