Endovascular Therapy in Acute Ischemic Stroke

Abstract

Rapid and effective revascularization is the mainstay of acute ischemic stroke treatment. Until recently, intravenous recombinant tissue-type plasminogen activator (r-tPA) was the only established therapeutic option. Five recently published trials have now proven the benefit of endovascular treatment, changing dramatically the evaluation and treatment of acute ischemic stroke.1–5 Thrombectomy with stent retrievers is now recommended as the standard of care for acute ischemic strokes with a proximal large vessel occlusion in the anterior circulation.6,7 In this article, we review the current evidence on endovascular therapy in acute ischemic stroke and discuss the major challenges in the implementation of this therapy. We address the challenges of the generalizability of trial results to different patient populations, implementation of endovascular therapy in the acute setting for large populations within various geographical contexts, and approaches to evaluating future innovations in the field of neuroendovascular care. The 4 pillars of successful revascularization with endovascular therapy to achieve a good clinical outcome are the following: 1. Rapid neurovascular imaging is critical to identify the eligible patient. All 5 positive randomized controlled trials used varying imaging selection criteria, including a minimum of a noncontrast computed tomography (CT) head to identify a small core using the Alberta Stroke Program Early CT score (ASPECTS) score and a computed tomography (CT) angiography of the head and neck to ascertain a proximal vessel occlusion.8 Vascular imaging also serves the interventionalist for planning the endovascular procedure. 2. Retrievable stents are safe and effective. Retrievable stents were used in the large majority of patients in all 5 trials with reported number needed to treat of 2.5 to 7 for an independent outcome at 90 days across the trials. Moreover, patient safety was preserved with very low overall procedural complication rates. 3. Time is brain. Analogous to the onset-to-treatment time …